Volume 15 Issue 1

ISSN: 1742-6456

BRITISH JOURNAL OF

ANAESTHETIC &RECOVERY NURSING

AN

AES

THETIC

ASSOCIATI

ON

NU

RSING

RECOVERY

www.barna.co.uk

Co-editors: Lucie Llewellyn and Theofanis Fotis

VOLUME XX ISSUE XX SEPTEMBER 2008MAY 2013VOLUME 14 ISSUE 1-2VOLUME 15 ISSUE 1 SEPTEMBER 2014

Volume 15, Issue 1, 2014

British Journal of Anaestetic & Recovery NursingThe Offi cial Journal of the British Anaesthetic & Recovery Nurses Association

The United Kingdom’s Offi cial Representative for the International Federationof Nurse Anaesthetists working in co-operation with the American Society

of PeriAnesthetic Nurses (ASPAN), the Irish Anaesthetic and Recovery Nurses AssociationWebsite: www.barna.co.uk

Editors: Lucie Llewellyn and Theofanis Fortis Email: [email protected]

Advertising: Lucie Llewellyn and Theofanis Fortis Email: [email protected]

BARNA COMMITTEE

Chair/IFNA representative: Manda Dunne Committee: Manda DunnePresident/Education: Pat Smedley Theofanis FortisTreasurer: Markku Viherlaiho Lucie Llewellyn Co-editors: Lucie Llewellyn and Theofanis Fortis Markku ViherlaihoSecretary: Pauline Guyan Pat SmedleyIFNA representative: Manda Dunne Joni BradyInternational Liaison: Joni Brady Sarah Dawkins Markku Ahtiainen

Membership EnquiriesMember: £30 (Nurse member) £40 (Associate member)

www.barna.co.uk

Subscription EnquiriesIndividual journal subscription: £58/$105

Institutional journal subscription: £210/$383

www.barna.co.uk

Editorial BoardJoni M Brady, MSN RN CAPA CLC, Pain Management Nurse - Nursing Administration, Perianesthesia Units clinical

practice Council Mentor, Inova Alexandria Hospital, Alexandria, Virginia, USAMary O’Brien, Senior Sister, Elective Orthopaedic Centre, Epsom, UK

Professor Mark Radford, BSc (Hons), RGN, PGDip (ANP), MA (MED ED), ENB 183, FHEA, Chief Nursing Offi cer, University Hospitals Coventry and Warwickshire NHS Trust; Visiting Professor, Birmingham University UK

Marianne Riesen, RNA, BSc Nursing, Member of IFNA Education Committee

Journal PrintingThe Warwick Printing Co Ltd, Caswell Road, Leamington Spa, Warwickshire. CV31 1QD

ProductionLawrand Medical Publishing, Lawrand Ltd, PO Box 51, Pontyclun, CF72 9YY

Tel: 02921 680068, Email: [email protected], Website: www.lawrand.com

The views expressed in articles are those of the author and do not necessarily refl ect the views of BARNA. The inclusion of advertising within the journal does not mean that BARNA or its members endorse the products or services advertised. Enquiries regarding any products advertised should be made direct to the company concerned.

British Journal of Anaestetic & Recovery NursingThe Offi cial Journal of the British Anaesthetic & Recovery Nurses Association

CONTENTS

From the Chairman

Change Can Be A Good Thing

Manda Dunne 5

Editorial

Editorial

Lucie Llewellyn 7

Original Articles

Peri-Operative HypothermiaLisa Jones (RGN) 9

2nd International Conference for Peri-Anaesthesia Nurses (ICPAN)

Pauline Guyan Sister, PACU 13

Identifying current UK airway management practices in the PACU

A report on BARNA Airway Audit 15

Notes to Authors 19

British Journal of Anaesthetic & Recovery Nursing Vol. 15 No. 1 © British Association of Anaesthetic and Recovery Nursing, 2014 5

British Journal of Anaestetic & Recovery NursingVol. 15 (1), 5

© British Association of Anaesthetic and Recovery Nursing, 2014From the Chairman

Change can have a profound effect on all those around us and can reach further than you realise, like ripples in a pond.

I have been reading about the NMC revalidation process which is currently under consultation and wondering how this will happen and how it can possibly affect our daily lives and the care we give our patients. Many years ago when I came into nursing, life seemed so pure and uncomplicated. My only purpose in my work life was to deliver the highest possible standard of care to my patients, always maintain a high professional position and smile constantly to make my patients feel happy. I remember the Nursing Offi cer’s of the time reminding us young nurses that you must never let how you feel (if it is negative of course) show in your face as the patient may notice and become upset. I have never forgotten this and realise how important that small piece of information was.

BARNA has been undergoing change quite a lot in the past couple of years which you have probably noticed. We are trying hard to make BARNA work better for our members and to reach out to as many other sources as we can to bring vibrancy and interest to the speciality of anaesthetic and recovery nursing.

We often feel like the forgotten speciality but I have realised how important it is to keep reaching out and talking about what we do to as many people as I can as it never ceases to amaze me how many of our own profession have absolutely no idea what we do on a daily basis!

The BARNA Conference took place in Greenwich this year on Friday 6th June and was quite an exciting event. It was in beautiful surrounds, actually the site of the old Royal Naval College, now Greenwich University.

There were a whole host of things to keep attendees occupied for the weekend, the Royal Park and Observatory, the Maritime Museum, Painted Hall, infamous Greenwich Market and much, much more not forgetting the Fan Museum!

We were very honoured that Dr. Peter Carter OBE, Chief Executive and General Secretary of the Royal College of Nursing, took time to be our keynote speaker. I had been looking forward to welcoming him and was very pleased that he joined us.

We had a stimulating line up of topics and I am sure the day was fun for everyone and you all went away with something new to take back to your work place or life in general.

The message I really want to convey to you all is please be patient with us at BARNA. We are working very hard to deliver the association you want and need and our passion for anaesthetics and recovery does not falter. Technology however is another matter!! However, I hope that you are seeing changes that are benefi cial and that our rippling pond reaches you and make you feel part of an association you are happy to be a part of.

I end this letter with these words from Winston Churchill:‘Every day you may make progress. Every step may be fruitful. Yet there will stretch out before you an ever-lengthening, ever-ascending, ever-improving path. You know you will never get to the end of the journey. But this, so far from discouraging, only adds to the joy and glory of the climb’.

Thank you,Manda DunneBARNA Chair Spring 2014

Change Can Be A Good Thing

Manda Dunne

BARNA Chair


Editorial

We would like to welcome you to the fi rst issue of the British Journal of Anaesthetic and Recovery Nursing with our new publisher. It has taken

some time to fi nd a publisher that will meet the needs of our association, but we hope that with this new partnership we will be able to deliver a journal that represents both our association and our members.

Within previous editorials the importance of using research to inform practice has been highlighted, and the fact that we need this evidence on which to base our practice, is crucial. However, this can be diffi cult when the research we rely on is limited or not as up to date as we would like. So what can we do?

A simple starting point is to identify a problem within your workplace that needs to be addressed and conduct an audit that can establish the extent of the problem. This has been used to great effect within a number of recovery and anaesthetic units, and changes have been made to practice. Audits are also a popular option among nurses when undertaking work based learning projects and dissertations, and again these fi ndings have been used to inform and change practice. However, the results of many of these audits are only shared within the units in which they are conducted, instead of being shared with other practitioners. As a result there are large pockets of information that are kept in isolation that would benefi t others if shared. One way in which these fi ndings can be shared to benefi t all practitioners is through their publication within journals such as the BJARN.

The diffi culty often lies in making the decision as to which is the most important problem to be explored, as there are many issues that need to be investigated. However, if this decision is made by a researcher, then that choice can be biased towards what they see as the priority and this does not always refl ect the need of the patient or the healthcare professional. This is an issue that is currently being

addressed through the Anaesthesia and Perioperative Care Priority Setting Partnership, which is being facilitated by the James Lind Alliance. BARNA is a member of this partnership and as a result we will be asking our members to contribute to this process through completing a survey that will be published this summer.

Through participating in the survey we will be able to help shape the future of research within Anaesthesia and Perioperative Care. By putting forward what we think are areas of importance, the ‘uncertainties’ that need to be explored can then be identifi ed, along with those from other patient and professional associations. From these uncertainties a list of ‘priorities’ are identifi ed, which will then be promoted to researchers and funders. The aim of this exercise is for research themes to be agreed upon from collaboration between patients and healthcare professionals. This will result in research being undertaken that addresses the needs of the patients and healthcare professionals it is aimed at, instead of it being based on the researcher’s own agenda.

Once the survey is released we will be contacting you, our members with the information you need to participate in this exciting opportunity to help shape the future of research within anaesthesia and perioperative care. If you are interested to learn more about the Priority Setting Partnership (PSP) process you can read more about the fi rst PSP that took place in 2009 in the British Journal of Anaesthesia (2012), 108(1).

Within this issue, we have the results of the latest BARNA audit, which may inspire you to share your audits and fi ndings. As always, we are keen to hear from you, and if you have been involved in any audits that you would like to share with fellow BARNA members, then the journal is the perfect place to share your fi ndings. Also, if you have an idea for an article but are unsure of how to get started then please get in touch via our email: [email protected]

British Journal of Anaestetic & Recovery NursingVol. 15 (1), 7

© British Association of Anaesthetic and Recovery Nursing, 2014

EditorialLucie Llewellyn

Co-Editor

International Collaboration of Perianaesthesia Nurses

ICPAN 2015

9th to 12th

September 2015

CONGRESS OFFICE DIS Congress Service A/S

Herlev Ringvej 2C DK-2730 Herlev, Denmark

Phone: +45 4492 4492

GENER AL I NFORM ATION Marianne Sjødahl

[email protected]

ICP AN 2015 LOC Bente Buch

[email protected]


Original Article

INTRODUCTION

This refl ection is based on an episode of care I experienced whilst working in a Day Surgery Department and is related to a patient that developed hypothermia during surgery. This refl ection looks at the causes related to why the patient became hypothermic and identifi es the preferred intervention to aid normothermia. This refl ection identifi es the errors that occurred within this episode of care and suggests future recommendations to promote patient safety. It briefl y touches upon the diffi culties and challenges within our practice that inhibit our ability to consistently deliver high standards of care. Names have been changed and confi dentiality maintained in accordance with the Nursing Midwifery Council (NMC, 2008). I have used Gibbs Refl ective Cycle (1998) to structure my essay. Gibbs (1998) refl ective cycle contains six key points; description, feelings, evaluation, analysis, conclusion and action plan. This is a useful tool that enables the learner to refl ect from experiences in practice to develop their personal and professional growth. This refl ection is structured using these six key stages, and therefore starts with the description of the recorded event.

DESCRIPTION

Mr Jones was a 70 year old man who came to the Day Surgery Unit for a Right Knee Diagnostic Arthroscopy. He arrived at 7AM in the Day Surgery Department, and had been fasted prior to his surgery since 9PM the previous evening. His vital observations were taken on admission and his temperature was 36.1ºC, which had clearly been documented on the patient’s care plan. During the intra-operative phase of his surgery, Mr Jones’ temperature had decreased and this was only identifi ed in the recovery room whilst taking his vital observations. Mr Jones stated that he felt cold, he was shivering, and complaining of pain in his right knee, and on assessing his temperature it was found to be 34.5ºC. There was no documented evidence that Mr Jones’ temperature was monitored throughout surgery, or any evidence of extra blankets or warming devices used during the intra-operative phase. I initiated a bair hugger (a warming device) to help increase Mr Jones’ temperature to make him feel more comfortable, as well as ensuring that he was receiving supplemental oxygen. It took an hour for his temperature to reach 36ºC, and for his pain to subside before I could return him back to the ward.

FEELINGS

I felt frustrated that Mr Jones had become mildly hypothermic as this was not a pleasurable experience for him and prolonged his stay in recovery, which I felt could have been prevented. I felt disappointed with the lack of communication and documentation that took place in this episode of care. I felt pleased to have identifi ed the signs and had the knowledge and experience to manage the situation independently.

EVALUATION

The good aspects were obtaining Mr Jones’ baseline observations during his assessment prior to surgery. It helped me to identify and initiate early treatment to prevent further risks from developing (Burger and Fitzpatrick 2009). I felt confi dent in dealing with the situation and I knew what equipment was available and how to use it. The bad aspects were the lack of communication and documentation, which lead to an unpleasant experience, prolonged recovery and increased healthcare costs to the trust (Lynch et al, 2010).

ANALYSIS

In adults core temperature ranges from 36.5ºC – 37.5ºC (NICE, 2008). Temperature is regulated by the hypothalamus which is situated in the brain, and receives messages from our peripheral and central thermo receptors to regulate our core body temperature (Paulikas, 2008). Core temperature remains the same, but our peripheral shell is variable and responds to physiological and behavioural changes to either lose or gain heat (Marieb, 2007).

Hypothermia is defi ned when the body’s temperature falls below 36ºC. There are several classifi ed stages of hypothermia, mild which is considered 32- 35ºC, moderate hypothermia at 28-32ºC and severe hypothermia is when the body temperature falls below 28ºC (NICE, 2008b). Inadvertent hypothermia occurs unintentionally, a common yet preventable complication that effects up to 70% of patients (Sessler, 2000). Therefore it is important to identify the risk factors associated with each individual patient. Assessments should take into account patients medical history, current general health, type of anaesthesia, and their length of surgery (NICE, 2008).

British Journal of Anaestetic & Recovery NursingVol. 15 (1), 9-12

© British Association of Anaesthetic and Recovery Nursing, 2014

Peri-Operative HypothermiaLisa Jones (RGN) Recovery Nurse, East Surrey Hospital, Redhill.

[email protected]


The consequences associated with Mr Jones developing inadvertent hypothermia, prolonged his stay in recovery and delayed his discharge. Thus consequently increasing healthcare costs to the trust (Lynch et al, 2010). No real harm was experienced but inadvertent hypothermia may have increased Mr Jones’ chances of developing surgical sites infections, pressure sores and arrhythmias that may have led to a myocardial infarction (RCN, 2008) and in severe cases mechanical ventilation, blood transfusion and mortality (RCN, 2008).

There were several risk factors associated with Mr Jones becoming mildly hypothermic. Age, fasting, wearing a thin gown, walking down cool corridors and being given cold fl uids intra-operatively were all contributing factors which lead to Mr Jones becoming mildly hypothermic (Summerbell, 2004). The elderly are more vulnerable to losing heat because as we get older our muscle mass decreases, and this muscle mass causes a reduction in the effi ciency of temperature regulation (Heggarty et al, 2009). As Mr Jones had fasted from the previous evening, his energy levels were reduced which could have caused his temperature to decrease, as we need energy to produce heat, which we obtain from food (Burger and Fitzpatrick, 2009). The fact that Mr Jones was wearing a thin gown and was transferred to theatre via cold corridors meant that his temperature could have already been reduced before his surgery had started (NICE, 2008c)

Whilst Mr Jones’ body was under the infl uence of anaesthesia he was vulnerable as his own protective refl exes were absent during surgery, due to the drugs given on induction and to maintain anaesthesia (Mulry and Mooney, 2012). Anaesthetic gases are known to cause the patient’s own mechanisms such as shivering to shut down (Lynch et al, 2010). The use of muscle relaxants would have further compounded this, as the ability to shiver would be inhibited (Marieb, 2007). Anaesthetic drugs and volatile agents inhibit the ability to shiver; this meant that Mr Jones’s natural ability to maintain and regulate his core temperature was reduced (Mulry and Mooney, 2012). An understanding of risk factors contributing to hypothermia help us to identify and appreciate the risks surgery poses to our patients (Mulry & Mooney, 2012).

In the recovery room Mr Jones was vulnerable and unable to control his own behavioural mechanisms to keep warm (Hasankhani et al, 2007). I observed Mr Jones shivering, which is a natural physiological response when our temperature decreases (Neno, 2005). Hypothermia is physiologically stressful to the body, as shivering increases metabolic demand and oxygen consumption, generating the myocardium to work harder. This can then cause an increase in blood pressure leading to cardiac events (Lynch et al, 2010). By delivering a steady fl ow of oxygen, arterial oxygenation will be maximised, thus enabling good tissue perfusion to minimise the risk of infection (Good et al, 2006).

Which is why I ensured Mr Jones receiving supplementary oxygen, as a reduction in white blood cells delivered to Mr Jones’ right knee, can inhibit the healing process (Lynch et al 2010).

I set the bair hugger temperature to 36ºC, aiming to raise Mr Jones’ temperature at a steady rate of 2º per hour (Hatfi eld and Tronson, 2002). Care was taken not to warm him too quickly as this could have caused dilation of the blood vessels, which could have resulted in a fall in his blood pressure (Fried, 2004). In the recovery room Mr Jones’ temperature was carried out every 30 minutes until his temperature reached 36ºC (Lynch et al, 2010). According to NICE, (2008) it is recommended that the patient’s temperature should be monitored at each stage of their peri-operative journey. This involves regular monitoring pre-operatively, intra-operatively and post-operatively. This is deemed good practice, and these measures were not carried out during this episode of care. However, obtaining Mr Jones’ baseline observations was useful, as it enabled me to identify and initiate early treatment to prevent further risks developing (Burger and Fitzpatrick 2009). The bair hugger was a useful devise and an effective intervention, as this resulted in Mr Jones feeling warm and comfortable (Paulikas, 2008), and his temperature being rectifi ed with minimal disruption.

The fact that there was no evidence of Mr Jones’ temperature being documented intra-operatively, leads me to assume it was not recorded. Documentation is a vital component in our professional code of conduct (NMC, 2008), and the clarity of information recorded is essential (Pirie, 2011). There are many infl uencing factors such as lack of motivation, knowledge, time restraints, disruptions, and tiredness that lead to poor communication and documentation (Junttila et al, 2005). This breakdown in communication compromised Mr Jones’ safety (Pirie, 2011) and could have lead to postoperative complications. Despite the cause of communication breakdown, we had a duty of care to Mr Jones and we should document objectively our nursing interventions to enable safe, effective care (Pirie, 2011). Failing to do this we leave ourselves wide open to facing disciplinary action that may lead to legal consequences (Austin, 2011). Good practice is to follow National and local policies, trust guidelines and remembering the core values of record keeping and documentation (NMC, 2008).

Recent evidence and guidelines support that pre-warming patients prior to surgery minimises inadvertent peri-operative hypothermia developing (NICE, 2008). Implementation of warming devises, warm irrigation fl uids and careful monitoring, documentation, communication and assessments are crucial elements in maintaining normothermia (Fried, 2004).

Peri-Operative Hypothermia


Having explored the up to date NHS evidence and Cochrane library, I discovered there were limited studies carried out on post-operative warming. However, a pilot study carried out by Cobbe et al, (2012) considered forced air warming to be the most effective means to warm patients. The disadvantages of this study were that it was a small sample size. A comparative study carried out by Leeth et al (2010), compared warmed cotton blankets and forced air warming involving 150 subjects. The results showed forced air warming achieved optimal comfort and cost saving of 19 pence per patient. However, Galvao et al, (2010), published a reviewed report, analysing the effectiveness of cutaneous warming methods, comparing water garments, cotton blankets and forced air warming. The results showed that water garments offer greater control compared to forced warm air warming devices. However these water garments are costly, and therefore may not be the best option available.

NICE (2008), recommend the importance of patient education and ensuring that they understand the importance of keeping themselves warm, in order to minimise inadvertent hypothermia. In addition to educating patients, the education of healthcare practitioners and clinical experience is essential to enable us to understand the meaning of inadvertent hypothermia and how we can prevent this from happening (Tame, 2009). Upon refl ecting on this scenario, I did not realise that patient education is instrumental to positive, safe surgical outcomes (Ortoleva, 2010).

I have not observed patients being educated regarding keeping warm in my department nor have I been encouraged to do this. Education and keeping staff up to date is costly and admitting patients in the morning is a busy period (Saunders, 2002). Nurses are already faced with time constraints and staff shortages (Dean, 2010). This is identifi ed in the Healthcare Commission staff survey, revealing nurses feel exhausted and tired with the growing demands the NHS is putting on them (Kendall-Rayner, 2009).

The National Health System (NHS) and NMC insist that we continue to develop and keep ourselves updated, yet the government have slashed the NHS budgets and now all trusts need to save 5% of their budget by 2015 (Snow, 2011). This in turn has increased our workload, we have become tired resulting in sickness and as a result agency nurses are implemented to help cover, costing the trust even more money (Parish 2009). The Royal College of Nursing (RCN) states that the NHS is struggling with the fi nancial cuts the government have implemented (Dean, 2011), yet ministers from the NHS organisation emphasise that we must be adequately staffed (Snow, 2010). We therefore fi nd ourselves stuck between a rock and a hard place.

ACTION PLAN

Upon refl ection, I should have raised this situation with a member of staff from the theatre team and written an incident report form as this may help to identify and correct errors for future practice. I feel we have become too familiar within our practice area as I have not heard or seen one incident report or legal enquiry linked with patients becoming hypothermic. I have designed a template for temperature recording that I will submit to my line manager to see if we can implement this within our unit and try to identify the areas of weakness that compromise patient safety as hypothermia causes signifi cant risk to our patients. I aim to carry out an audit on the various devices used for temperature monitoring in my practice area, as I feel we get different readings from different devices. The results I obtain from the audit will help identify areas where we can improve practice and patient safety outcomes. I feel it is imperative that we all use one device which we can all understand and clearly read. Having explored literature relating to hypothermia, I have discovered there are other warming devices that I wish to explore in the near future. The knowledge I have gained from the module I have recently studied I will share with my colleagues, but more importantly the knowledge has given me the confi dence to challenge and correct bad practice.

CONCLUSION

It is a team effort to take responsibility in keeping our patients warm. An understanding of peri-operative hypothermia and the physiology of how the body responds to changes are instrumental in delivering effective care. Management is better than cure; and the management of preventing inadvertent hypothermia involves us in risk assess, continuous monitoring of our patients is vital in delivering positive patient outcomes. The importance of teamwork, communication and documentation are key components in keeping our patients safe. This article highlights that education is key for staff and patients. However, time, money and resources restrict our ability to practice to these standards and recommendations. Despite these tough times we all have a duty of care to do no harm, and we as professionals have a duty of care to keep our skills updated, follow local guidelines and procedures, and act within our limits and competencies. We must remember we our accountable for our actions to ourselves, patients and our profession.



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documentation”, British Nursing Journal, 25, 25030

Burger, L. and Fitzpatrick, J. (2009) “Prevention of Inadvertent Peri-operative Hypothermia”, British Journal of Nursing, 18(18), 1114-1119

Cobbe, K., Staso, R., Walker, K, and Draper, N. (2012) “Preventing Inadvertent Hypothermia: Comparing two protocols for peri-operative forced air warming” Journal of PeriAnesthesia, 27(1), 18-24

Dean, E. (2011) “Increasing Staff Shortages are compromising quality of care”, Nursing Standard, 25(29), 9

Dean, E. (2010) “Low Staffi ng Levels Contribute to On-going Problems at Mid Staff”, Nursing Standard, 25(9), 10

Dougherty and Lister (2011) Clinical Nursing Procedure. 8Th ed. Blackwell Publishing, Oxford.

Galvao, C., Liang, Y., and Clark, A. (2010) “Effectiveness of Cutaneous Warming Systems on Temperature Control: Meta analysis” Journal of Advanced Nursing, 66(6), 1196-1206

Gibbs, G. (1998) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford.

Good, K., Verble, J., Secrest, J. and Norwood, B. (2006) “Postoperative Hypothermia-The Chilling Consequences”, Acorn Journal, 83(5), 1055-1070

Fried, D. (2004) “Hypothermia’s Chilling Effect on Outcomes”, 22-23

Hatfi eld, A. and Tronson, M. (2009) The Complete Recovery Room Book. 4th ed. Oxford, Oxford Medical Publication

Hasankhani, H., Mohammadi, E., Moazzami, F. Mokhtari, M. and Naghgizadh. (2007) “The Effects of Intravenous Fluids, Temperature on Perioperative Hemodynamic Situation, Post-operative Shivering, and recovery in Orthopaedic Surgery”, Canadian Operating Room Nursing Journal, 25(1), 20-27

Hegarty, J., Walsh, E., Burton, A., Murphy, S., O’Gorman, F. and McPolin, G. (2009) “Nurses Knowledge of Inadvertent Hypothermia” Journal of Advanced Perioperative Care, 4(1), 33-42

Junttila, K. Salantera, S. and Hupli, M. (2005) “Perioperative Nurses’ attitudes towards the use of nursing diagnoses in documentation” Journal of Advanced Nursing, 52(3), 271-280

Kendall-Rayner, (2009) “NHS Staff Survey Shows Nurses Feel Overworked and Understaffed” Nursing Standard, 23(30), 10

Leeth, D., Myrna, M., Oman, K. and Krumbach, B. (2010) “Normothermia and patient comfort: A comparative study in an outpatient surgery setting”, British Journal of Nursing, 25(3), 146-151

Lynch, S., Dixon, J. and Leary D. (2010) “Reducing the Risk of Unplanned Perioperative Hypothermia” Acorn, 92(5), 553-565

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19th - 22nd September, 2013

Pauline Guyan Sister, PACU York Teaching Hospital NHS Foundation Trust

Original ArticleBritish Journal of Anaestetic & Recovery Nursing

Vol. 15 (1), 13-14 © British Association of Anaesthetic and Recovery Nursing, 2014

Perusing the posters proved a productive time to talk to members of the teams that had developed and initiated change. The winner in the Innovative practice category was Cindy Rizzoli from Canada, with the poster title of ‘Supraclavicular Nerve Block: Future Practice for the Pain Control, Saving Time and Saving Money’. In the Research category it was Phyllis Mesko from the USA, with the poster titled ‘Establishing Reliability and Validity of the Mesko-Elades Pain Area Locator tool (PAL) in pediatric post-operative patients’. Well done to both of them and congratulations to all those who put so much work and effort into producing great educational and innovative material for their posters. This would have taken some judging, as the content and the work that had gone into these posters was most inspirational.

The multinational organising committee had prepared an exciting educational programme refl ecting current trends in peri-anaesthesia. The programme began with a huge show and waving of international fl ags with in excess of twenty countries represented. BARNA’S past president and valued member of the ICPAN committee, Pat Smedley was there with her Union Jack in the form of a scarf representing the UK and in the audience too, the representatives of BARNA and the UK sported their Union Jacks.

It was quite a moment of pride I am convinced for each and every country represented and not depending on size or attendance. Very much a warm feeling of “Many Practices…. Just one world”, as the slogan for the fi rst ICPAN conference in Toronto suggested.

It was diffi cult to choose which sessions to attend. The thoughts that went through my head were, should I go to the sessions which are topical right now in our area of practice within peri anaesthesia? For example; ‘CPAP from intermittent to continuous’, presented by PACU nurse Lara Henningsen. She guided the audience through the work they are doing in Denmark. This demonstrated how the PACU nurse can develop the quality of CPAP treatment for the patients needing extended observations in PACU.

It was an honour to have the opportunity to attend the 2nd International Conference for Peri-Anaesthesia Nurses in the City West Hotel, near the medieval capital city of Dublin, in Ireland.

The International Conference for Peri-anaesthesia Nurses (ICPAN) initially came about from an idea of several international nurse colleagues while socializing in a London pub back in 2008. They had been attending a British Anaesthetic and Recovery Nurses Association (BARNA) annual meeting. Here they discussed the possibility of hosting a collaborative global conference and as this was met with such enthusiasm, the fi rst uniting of global nurses in peri – anaesthesia, anaesthetic and recovery was held in Toronto Canada in 2011. It then seemed extremely fi tting that the Irish Anaesthetic and Recovery nurses Association (IARNA) hosted this the second conference as 2013 has been named ‘The Year of the Gathering’ and what a warm welcome we received on 19th September.

I was astounded by the distance that nearly four hundred Peri-Anaesthetic nurses had travelled to be part of this hugely successful conference. They arrived from across the globe and we had such a wonderful opportunity to speak and network with them during the week end. Having organised study days in my own hospital and realising that many of us around the UK experienced similar issues in Peri anaesthesia, I found it even more astonishing that many of the issues within our clinical areas are also experienced globally. These include staffi ng issues and ratios; delayed discharges to wards; beds not available on the ward causing a backlog within PACU; also ICU/HDU patients in PACU to name but a few of these.

Acknowledging this, it was wonderful to see how nurses remain enthusiastic and are continually working not only to improve clinical practice but also the patients’ experience while passing through our clinical areas, amidst the continually changing climate we experience in healthcare today. This was clearly demonstrated in the wealth of innovative practice and research, seen in the forty strong poster displays.


It was refreshing to hear Lara particularly as she stated that she was only a nurse and hadn’t any letters after her name, yet she was able to get involved in this valuable work. This should encourage those nurses in the audience to become involved in improving patient outcomes and audit etc. Perhaps the monitoring of CO2, ‘Capnography in your PACU’ by Maureen F McLaughlin would be a timely subject for many. While this is standard practice in most operating theatres and recommended by the anaesthetic associations it is slow to be considered as routine in the PACU. My considerations were given also to ‘Obesity and the surgical patient’ clearly presented by Kathy M Sherry as this is a very up and coming topic with the ever increasing population of obese patients. What about attending the ones which are routine practice that I could become complacent about but really could do with updating, for example ‘Current best practice and evidence for prevention and management of PONV’ by Jan Odom-Forren, all the way from Kentucky. Management strategies used by patients at home after surgery was discussed, as were methods to assist patients in symptom management. Kim Litwack with her wealth of knowledge from the USA was to present ‘Pain Assessment across the Life Span’ whereby evidenced based assessment scales and tools were presented to allow practitioners to better access and manage pain in the paediatric patient. Malignant Hyperthermia which as a possible anaesthetic emergency, although a rare occurrence, is one that nurses need to be well versed in the treatment of, was presented by Paula Foran from Australia.

One of the other groups considered were the topics that I had very little knowledge or evidence for; for example ‘Caring for the patient with Autism Spectrum Disorder in the perioperative setting’. This was to be delivered with a wealth of knowledge and very personal experience by Phyllis J Mesko. She demonstrated a toolkit of ideas to help when providing care to improving the experience for the patient, family and the nurse. Theofanis Fotis, our very own committee member for BARNA presented on the ‘Cost effectiveness Comparison of the Airway Management of Patients undergone EVAR between ETT vs. LMA’ showing results of a study which compared cost, effectiveness and patient’s satisfaction.

I decided that whichever sessions I went to, I was going to be disappointed at not being able to listen to them all. So I did, as I guess many of the other delegates did, and I took a range of topics from each of my categories and was not disappointed with my choices in any way. One particularly has very much stayed with me, and I consider that this is the one that will have the most impact on my practice and that of my team from now on moving forward, due to the thought provoking content. I attended Jamie Mann- Farrar’s powerful lecture on the very fi rst morning which was titled ‘Can’t Intubate, Can’t oxygenate: Converging Practice Down under?’ Jamie is a Director of Nursing in Tazmania, Australia. My own thought process misled me into thinking this would be a very practical guidance on what to do in this situation which has possibilities of mortality and morbidity, with perhaps the experience of those that had met with this critical situation. This was to be much more than that. Jamie compared Aviation safety with that of Healthcare in regards to safety. He explored how the two have many things in common for example, lots of checklists; ability to create sensational news; wear uniforms; make amazing profi ts; use simulation; emergency procedures; and both are capable of miracles. However, aviation has an invested interest in safety with high customer participation in safety briefs .Patients are not always involved in healthcare safety checks nor do they always want to participate. Should patients be involved in the WHO checklist and safety brief? He gave many examples of where human factors can reduce safety resulting in the ‘swiss cheese model’ effect for examples drugs in similar packages,

drugs poorly written; machines doing the same job but different makes although look alike. Actions can be taken to design things in a way to promote getting the planned action every time. Jamie then homed into ‘Can’t Intubate, Can’t oxygenate’ with suggestions of procedural respect. His suggestions demonstrated in the following ways; the setting up the intubation trolley in every anaesthetic room to be the same. Having a set ‘Red’ area for emergency equipment, bag, valve mask, suction and O2 cylinder. Where these are positioned on a wall they are stencilled in blue in the shape of that piece of equipment and therefore at the start of an airway procedure, reciting ‘if we see blue, we hold off touching you’ until all emergency equipment is in place. Colour coding emergency equipment to the procedural algorithm. Use of tamperproof seals and checking less often, but increase training and simulation around the equipment in the trolley. Give ownership to a group of practitioners to bring emergency equipment i.e. Anaesthetics bring the diffi cult airways trolley, PACU bring the Crash Wagon. Undertake multi-disciplinary training on a regular basis; use simple aid memoires and maintain silence when starting any airway procedure. These were simple but constructive and effective suggestions to increase safety for our areas and for our patients. He very much promotes departments reviewing practice, implementation of human factor design systems and the provision of theatre wide education, training and simulation.

The interactive sessions ‘Gathering of the Nations’ Forum, promoted discussion relating to perianaesthesia practices globally. Issues relating to competencies required for working in anaesthetics and PACU, particularly pertaining to the Advanced Practitioner role. Issues affecting effi cient patient fl ow in the PACU and discharge criteria, scoring systems and audit all differ in each country. Although many issues were experienced across the world it would appear that with all the rules and regulations of individual countries, it would make it diffi cult to develop international standards. Although it was felt that this was an area which could be developed more and this would be discussed in the future development of ICPAN . Globally we all stand together with many similar issues to overcome.

It is diffi cult in this short article to relate all the work that is going on across the globe that is innovative within research but hopefully this is demonstrated in a few of the many presentations of this three day conference. The presentations are available on the ICPAN website.

The warm welcome of the Irish was further demonstrated in the social programme they had planned so very well. We were given a choice of visiting a couple of Dublin hospitals, St.Vincent’s or the Beaumont or attending an evening Symposium, ‘Enhanced Recovery & Maintenance of Intraoperative Normathermia’ sponsored by 3M. I chose the visit to St Vincent’s as although our goals are comparable, the way we achieve these may differ and lessons may be learned. We also experienced a very enjoyable evening at the Old Jameson Distillery with a tour, followed by some wonderful Irish culture, food, dance and music.

The conference did exceed my expectations and allowed me the opportunity to learn from my colleagues, meet colleagues from far and wide and enjoy the Irish hospitality. Thanks go to the ICPAN committee for all the hard work they have attributed to conference planning and special thanks to the Conference chair Ann Hogan and her committee for all their input and the provision of seamless arrangements to and from Citywest and during the whole week-end with that special Irish hospitality.



Identifying current UK airway management practices in the PACU:

A report on BARNA Airway Audit

Original ArticleBritish Journal of Anaestetic & Recovery Nursing


INTRODUCTION

The British Anaesthetic and Recovery Nurses Association undertook a national audit of airway management procedures in 2013, following the draft report submitted for consultation by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2012. The AAGBI (2012) stated that “on many occasions, patients will be handed over to the PACU nurse with a laryngeal mask airway or other supraglottic airway device in place. The nurse must be specifically trained in the management of these patients and in the removal of the airway device. The removal of tracheal tubes from patients in the PACU is the responsibility of the anaesthetist, who may delegate the removal to an appropriately trained member of the PACU team who is prepared to accept this responsibility”. The draft guidelines then became their publication Immediate Post-anaesthesia Recovery 2013 (AAGBI 2013).

BACKGROUND

A Framework for Lifelong Learning in the NHS (Department of Health 2001) stated that nurses need to be able to refl ect, evaluate and modify their practice, ensuring that they are up to date with current research and legislation. The purpose of this audit was to gain insight into all of the UK’s PACU/Recovery areas airway management practices in relation to the AAGBI’s (2013) guidelines and to explore whether staff within the PACU areas were changing their own practice in light of it.

THE AUDIT DESIGN AND DISTRIBUTION

Permission was sought from UK PACU Nurses/Managers to take part in the audit. These were predominantly senior staff, however some junior staff assisted with the completion of the audit as they had the knowledge required to do so. The audit was then disseminated, via email to those staff. Due to the anonymity and to reduce duplication of results, only one audit was sent to each PACU area.

The audit was designed in two parts, the fi rst half being about Laryngeal Mask Airways (LMAs) and the second half about EndoTracheal Tubes (ETTs). The majority of questions were mostly closed to allow for quick answers and gain quantitative information. However, some open questions were added to gain qualitative information.

RESULTS

Questions relating to LMA/I-gel management

Q1. On an average day how many patients are admitted to PACU with an LMA/I-gel in situ?

A: Answers ranged from 1– 60 and 40 - 80% with some areas stating they rarely use LMAs/i-GELs and others using them on most patients.

Q2. What training is provided for the PACU staff in the management of LMA / I-Gels [including removal]?

Q3. Who normally removes the LMA / I-gel from the patient?

Q4. Who is responsible for assessing the competency of PACU practitioners in LMA / I-gel removal?

A: Competency assessment came from a variety of sources from Band 5 experienced PACU staff/peers to senior staff/managers, clinical teachers, mentors, practice educators and Anaesthetists. Two responses documented that they were not assessed.

Q5. How is this assessment carried out?

Q6. Are there any written protocols on the management and removal of LMA / I-gels?

A: 23 responses stated there were no written protocols within the hospital trust and 3 were not sure. Others documented corporate guidelines, BARNA guidance, SOP (Standard Operating Procedures), evidence based research, manufacturer guidelines, policies and procedures documents kept in Recovery, ILS and regular training with Anaesthetists.

Q7. If emergency airway intervention is required are any of the PACU staff trained to insert LMA / I-gels?

Q8. If you ticked any selection in Question 7, please describe how this training is achieved?

Formal Training Informal TrainingIn house On the jobStudent Airway Package Peer TrainingALS / ILS / BLS DidacticPACU / Perioperative Course Competency Based AssessmentRecovery Competency Training Supervision by Senior Staff / AnaesthetistsLMA Company Backed Training ShadowingAnaesthetic Nurse Training

Staff Type Numbers IdentifiedPACU Nurses / Practitioners 42ODP’s 5Anaesthetic Nurses 0Anaesthetists 10

Formal Assessment Informal AssessmentInduction Programme Direct Observation / Visual AssessmentSimulation Mentor / SupervisionCompetency Documents Questioning / Discussion

Working with Anaesthetists

Type of Airway Intervention Numbers Trained to Insert AirwaysLMA 16I gel 15Both 9

Formal Training Informal TrainingALS / ILS / BLS Working with AnaesthetistsInduction Working with Anaesthetic NursesIn house Working with ODPsSimulation / Clinical Skills Laboratory


Questions relating to ETT management

Q9. In the course of one week how many intubated patients are admitted to your unit?

A: most reported 0 – 6 intubated patients. Thirteen respondents reported between 10 and 105 and one documented 20% of patients.

Q10. What are the most common reason[s] for patients being intubated on admission to PACU?

A: The responses fall into three categories – to allow the Anaesthetist back into theatre to continue with the lists (time issues), type of surgery (patient position ie. prone) and clinical emergency/waiting to go to ICU. One answer documented “laziness”.

Q11. Who normally makes the decision to extubate the patient in PACU ?

Q12. Who normally extubates the patient in PACU?

Q13. If the Anaesthetic Nurse, PACU Nurse or ODP makes the decision to extubate the patient, how do they assess the patient is ready to be extubated?

Others highlighted that if the patient was gaging, coughing on the tube, spontaneous breathing, excellent saturations, fully awake, clinical assessment, cardio-vascularly stable and one documented “no expertise”.

Q14. If the patient requires a repeat dose of a reversal agent prior to extubation, who administers this drug?

Q15. Who carries out the fi nal assessment to ensure that Anaesthetic Nurses / PACU Nurses or ODP’s are competent to extubate patients?

Staff Type Numbers IdentifiedAnaesthetist 31PACU Nurse 14Anaesthetic Nurse 2ODP 2

Staff Type Numbers IdentifiedAnaesthetist 31Anaesthetic Nurse 4PACU Nurse 18ODP 5Respiratory Therapist 1

Type of Assessment Numbers IdentifiedClinical Expertise 19Set / Agreed Protocol / Competency 11Not Applicable 1

Staff Type Numbers IdentifiedAnaesthetist 37PACU Nurse 2Anaesthetic Nurse 0ODP 0Other 0

Staff Type Numbers IdentifiedAnaesthetist 12PACU Nurse 7Clinical Assessor 8Anaesthetic Nurse / ODP 3Others 6

Q16. How many times does a practitioner have to extubate a patient to be found competent?

A: The answers ranged from 1 to 50, as many times as required, assessed on an individual basis and depends on local protocol. Some answered that no assessment or guidelines were in place.

Q17. In your unit do you have guidelines/protocols to follow if emergency re-intubation is required?

Q18 In your PACU is there a member of staff [non anaesthetist] trained in intubation?

Q19. If the answer to the previous question was ‘yes’ what training have they received?

A: None, ALS, simulation and as part of Anaesthetic Nurse training.

Open ended questions relating to airway management / airway incidents

Q20. To what extent do you think time constraints in theatre impact on the airway management of patients in PACU? [eg early extubation in theatre or prolonged intubation in PACU? ]

A: Many highlighted early/deep extubation in theatre leading to airway problems, needing support, airway adjuncts and manual ventilation of patients within PACU, therefore not allowing patients to wake up themselves. ETTs being replaced with LMAs to speed up transfers and the Anaesthetist needing to return to theatre to complete the lists on time. Others state there are no or few problems.

Q21. Please describe any examples of airway incidents you have encountered resulting from lack of proper training or supervision in the management of LMA / I-Gel or endo-tracheal tubes in PACU:

A: Most respondents in the audit documented that they had no airway incidents due to appropriate training. One response stated that “a patient was lost one week” whilst another reported that “July is a problem month when new residents come on staff”. Jaw support and airway adjuncts were needed in some cases and inadequate reversal was identifi ed as a cause of problems. An incident was sited where “a Nurse removed an ETT thinking it was an LMA”.

Others stated laryngospasm, expelled airways, teeth pulled out, not breathing/obstructing, biting the airway, not realising they could defl ate a cuff, lack of suctioning, desaturation and re-intubation as problems.

Guidelines Available Numbers IdentifiedYes 20No 18

Staff Trained Numbers IdentifiedYes 3No 37

Identifying current UK airway management practices in the PACU: A report on BARNA Airway Audit


Questions relating to demographics

Q22. What is the nature of your PACU?

Q23. Where is your hospital situated within the UK?

Q24. What is your role in PACU?

Q25. If you are a PACU practitioner [i.e. not a manager/educator] please identify your role and number of years of experience in this role :

A. Time served ranged from 2 – 42 years in posts.

Q26 If you have a written policy : procedure : competency on any of the areas of non-physician adult airway management in PACU discussed in the audit, would you kindly send an e-copy or scanned copy?

ANALYSIS

This audit highlights that the majority of PACUs do not accept patients with ETTs, preferring to only accept LMAs or extubated patients. The Anaesthetist needing to return to the theatre to continue with the daily lists in order to reduce theatre delays was reported as a problem shared by many. The consequence of this is that patients in PACU requiring airway support either through jaw support, the insertion of an airway adjunct, or manually ventilating. According to Rassam et al (2005) and Karmarker and Varshney (2008), airway related complications at extubation are more common than problems at intubation, many aspects of which are controversial with no clear guidelines, giving cause for concern for patient safety and training.

This audit indicates that some PACUs have formal/dedicated training/induction programmes for new staff to learn airway removal procedures for patients with LMA’s, while others put their staff through ALS/ILS/BLS training to learn airway management.

Nature of PACU Numbers IdentifiedAttached to Main Theatre 36Day Surgery 9Specialist 0Paediatric / Oncology / Orthopaedics 1

Area Numbers IdentifiedLondon 7South East 7South West 4 4South Central 1Midlands 6North East 1North West 5Wales 2Scotland 1

Staff Type Numbers IdentifiedUnit Manager 14PACU Practitioner 15Practice Educator / Development Nurse 0Anaesthetic Nurse 2Clinical Manager 3PACU Nurse Manager 1Supervisor 2Junior Sister 1Matron 1

Staff Type Numbers IdentifiedAnaesthetic Nurse 4PACU Nurse 21ODP 1

Policy Numbers IdentifiedNo Policy 20Policy to Share 4Policy Not Sharing 5

Those that use informal training tend to use supervision and competency documents to assess extubation/airway removal competency and capability for staff. According to the results of the audit, it appears to be the clinical decision of the PACU staff that dictates when the patient has the airway removed, rather than any policy or protocol. The Anaesthetist was defi ned through the audit as the person that makes the decision and extubates the majority of the patients as well as administering any reversal needed. It is also the Anaesthetist that carries out the fi nal assessment, declaring PACU practitioners competent to extubate/remove airways. This is predominantly based upon the PACU practitioner’s confi dence and competence rather than an exact number of witnessed procedures. Most of UK PACUs audited here are able to manage their patient’s airways successfully, with few harmful events.

It appears that less than half of all the PACUs that responded to the audit have documented policies/guidelines for LMA/I-gel removal or emergency (re)intubation and virtually all staff are unable to intubate patients. Yet, if the insertion of an LMA/I-gel was required, almost half of the respondents could undertake this airway management task.

LIMITATIONS

The audit was initially emailed out without the ability to move onto the next question if some questions were not answered, meaning that a wrong answer may have been documented to be able to complete the audit. Once this was highlighted, the survey was restructured and re-emailed out and all numerical data is taken from the second audit.

Limitations identifi ed are a small cohort as only 44 audits were undertaken and due to the anonymity of the audit, it is not clear if only one person from each of the PACU areas completed it. The results might not correlate nationwide as generalisations cannot be made.

A lack of overt differentiation between the removal of an LMA and the extubation of an ETT may have caused false answers. Differentiation cannot be made between the PACU Nurse, Nursing Staff and Anaesthetic Nurse in open questions due to a lack of defi ned structure and many answers stating “Nurses”.

CONCLUSION

This audit has produced a lot of interesting information. It has highlighted differences in airway removal and extubation practices throughout the UK and much has been learnt from it. This could be used as a pilot study for a more controlled audit in the future.

From the information supplied within the audit, many PACU Practitioners receive training for airway management to remove LMAs and I-gels either formally or informally. Yet, the responsibility for removing ETTs remains with the Anaesthetist, despite the AAGBI’s (2013) guidelines stating this responsibility could be delegated. However, delegation is a two way process and according to Burnard & Morrison (1994), the person to whom the task is delegated has a duty to inform the Anaesthetist delegating the task if the task is outside their area of competence. The Association for Perioperative Practice (AfPP) further states that if the responsibility is delegated, the practitioner should have received validated training and be deemed competent to perform the task (AfPP 2007).

If needed, BARNA could assist with the provision of a national training protocol for the removal of LMAs, I-gels and extubation, adding to the work already completed by Dawkins (2011) Nurse led extubation.



REFERENCES

Association for Perioperative Practice (AfPP) (2007) Standards and Recommendations for Safe Perioperative Practice Harrogate AfPP

Association of Anaesthetists of Great Britain and Ireland (2012) Draft Report of the AAGBI Immediate Post-Anaesthetic Recovery Working Party July 2012. AAGBI [online] Available: http://www.aagbi.org/sites/default/fi les/images/Immediate%20post-anaesthetic%20recovery%20for%20members%5B1%5D.pdf Accessed 24/11/12

Association of Anaesthetists of Great Britain and Ireland (2013) AAGBI Safety Guidelines. Immediate Post-anaesthesia Recovery. London AAGBI


Burnard P, Morrison P (1994) Nursing research in action. Basingstoke. Palgrave Macmillan

Dawkins S (2011) A literature review and guidance for nurse-led patient extubation in the recovery room/post anaesthetic care unit: endotracheal tubes Journal of Perioperative Practice (2011) Vol 21 (10) pp 352 - 355

Department of Health (2001) A framework for lifelong learning for the NHS. London. Department of Health

Karmarkar S, Varshney S (2008) Tracheal extubation British Journal of Anaesthesia 8 (6) 214-20

Rassam S, Sandbythomas M, Vaughan RS, Hall JE (2005) Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland Anaesthesia 60 (10) 995- 1001


Information for Potential Authors

Notes to AuthorsBritish Journal of Anaestetic & Recovery Nursing


The British Journal of Anaesthetic and RecoveryNursing publishes the following types of articles,but welcomes any submission of relevance:

� Editorials� Original articles� Original research� Study day and conference reports� Correspondence� Case reports� Notices� Review articles� News articles� Audit reports� Unit Interviews (www.barna.co.uk) Select ‘BJARN’

then ‘Introduce Your Unit’

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Authors are requested to submit a copy of theirtypescript as a ‘word’ document, preferably by emailas the Editor cannot accept responsibility for damageto/or loss of material discs. When a paper is acceptedfor publication, it is done so on the understandingthat it is not being submitted simultaneously to anyother journal in the English language. The Editor willmake editorial and literary corrections as she sees fit.Any opinions expressed or policies advocated donot necessarily reflect the opinions or policies of theEditor or the British Anaesthetic and Recovery NursesAssociation. Any article submitted should contain:

� Title of the article� Initial and name of each author� Relevant qualifications� Name and address of the department or institution to

which the work should be attributed� Name, address, telephone number and e-mail address

for the author responsible for correspondence� Abstract or summary and section headings if suitable

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All diagrams, pictures or illustrations should have ashort description or caption sent with them. Titlesshould appear above each table or figure. They shouldalso be referred to in the text. Photos should be sent asan attachment and as a jpeg file, along with where youwish them to be placed.

HARVARD REFERENCING

References should be presented in the Harvard style.The accuracy of the reference you provide is yourresponsibility. In the text your reference should state the


author’s surname and the year of publication e.g.[Smith, 2002] unless the reference is at the beginningof the sentence when only the date is put in bracketse.g. Smith [2002] states y If there are two authors, youshould give both surnames [Smith and Black, 2001].When a source has more than two authors, give thename of the first named author followed by ‘et al’,however do not use et al in the reference list, creditmust be given to all authors. Where a quotation is usedwithin your paper; the author, date and page numbershould be given, e.g.

‘For many years the recovery unit has been viewedas the ‘‘Cinderella’’ of the operating department.Indeed twenty-five years ago many hospitals didnot have recovery units and post surgical patientswere recovered on the surgical wards directly fromtheatres.’ (Oakley and Spiers, 2004 P 137)

A list of all the references in your manuscript shouldbe typed in alphabetical order, on a separate sheetentitled ‘References’ at the end of the paper. Eachreference to a paper needs to include authors’ surnamesand initials, year of publication, full title of paper, fullname of journal, volume number, and first and last pagenumbers. References should conform to the Harvardstyle. Here is an example:

Wilson S, Forrester A (2002) The way forward foranaesthetic and recovery nursing. Accident and EmergencyNursing 13(1), 1–8.

References to books should be given in a slightlydifferent form, as in this example:

Radford M, County B, and Oakley M (2004) AdvancingPerioperative Practice. Cheltenham: Nelson Thornes.

When using an edited book, the author of the chapterwill be used in the text and in the reference list and willbe referred to in the following way:

Oakley M and Spiers C (2004) Chapter 6 Principles ofRecovery Practice. IN Radford M, County B andOakley M (2004) Advancing Perioperative Practice.Cheltenham: Nelson Thornes.

Secondary references can be used, but overall theseshould be avoided. With the advent of the internet thereare very few primary sources that will be unavailable toauthors. The rationale for using a secondary referenceis that the author is unable to find the primary sourceand must therefore use the secondary reference. If asecondary reference has to be used, the text shouldread; Smith [1978] cited by Brown [2004]. In thereference list it is Brown that is listed as the reference,because if the Smith reference had been used it wouldbe the primary reference.

LETTERS TO THE EDITOR

Readers are welcome and encouraged to write aboutany topic that relates to the practice of anaesthetic andrecovery practice or relevant to contents of the journal.Such letters will be published under ‘short communica-tion’ and can be in relation to something you have readin the journal, or an item of news, etc.

WE ARE WAITING FOR YOUREMAILS AND PHONE CALLS

The Editor in Chief and relevant members of the committeewould be pleased to hear from any potential authors. Pleasedo not hesitate to contact us. If having your work publishedsounds like a scary prospect, drop us an email and we willoffer advice and support and start you on the road to beingin print. Publishing in the British Journal of Anaesthetic andRecovery Nursing is an excellent opportunity for profes-sional and personal enhancement. So come on, yourjournal is growing: Be part of it.

information for potential authors’ to:Lucie Llewellyn and Theofanis Fotis, Editors-in-Chief,E-mail: [email protected] UK1st Floor Chesterfield House385 Euston RoadLondonNW1 3AU

Notes to Authors

FROM THE CHAIRMAN● The Power Within You

Manda Dunne 1

EDITORIAL● From the Editor’s Perspective

Theofanis Fotis 2

ORIGINAL ARTICLES● Effect of Pre-warming on Reducing the Incidence of

Inadvertent Peri-operative Hypothermia for Patients Undergoing General Anaesthesia: A Mini-reviewLucie Llewellyn 3

● Parental Refusal of Consent for their Child’s Medical Treatment: An Ethical, Professional and Legal DilemmaLiz King 11

● Shoulder Operation Counselling in Day-Surgery Patients in Finland: Patients’ PerspectiveTerhi Haapala, Mira Palonen, Päivi Åstedt-Kurki 18

EDUCATION● Innovation the EOC Way

The Appointment of a Transfer Link Nurse: Is it the Answer to a Busy PACU’s Prayers?Jessica Inch, Suzanne Tyne 26

CONFERENCE REPORT● The Irish Anaesthetic and Recovery Nurses Association

(IARNA), 11th National Conference, 29 September 2012, KilkennyPauline Guyan 30

PROFESSIONAL ISSUES● BARNA Members and Non-members Need Defending

Markku Viherlaiho 34

NOTES TO AUTHORS 36

BRITISH JOURNAL OF

ANAESTHETIC & RECOVERY NURSINGCONTENTS

SEPTEMBER 2008VOLUME XX ISSUE XX MAY 2013VOLUME 14 ISSUE 1-2VOLUME 15 ISSUE 1 SEPTEMBER 2014

FROM THE CHAIRMAN

Change Can Be A Good ThingManda Dunne 5

EDITORIAL

EditorialLucie Llewellyn 7

ORIGINAL ARTICLES

Peri-Operative HypothermiaLisa Jones (RGN) 9

2nd International Conference for Peri-Anaesthesia Nurses (ICPAN)Pauline Guyan Sister, PACU 13

Identifying current UK airway management practices in the PACUA report on BARNA Airway Audit 15

NOTES TO AUTHORS 19

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