Capnography ‘tea trolley’ training

Published: 21/04/2022 | Author: Dr Victoria Poyntz and Dr Olivia Burke

Glenda Logsdail died after an unrecognised oesophageal intubation led to a prolonged period of hypoxia and subsequent irreversible brain injury. Four of the factors identified by the coroner investigating her case were the failure to actively exclude oesophageal intubation when a flat capnography trace was seen, lack of familiarity with the Royal College of Anaesthetists and Difficult Airway Society No Trace = Wrong Place campaign, a steep team hierarchy and poor teamwork.

To raise awareness of the Glenda Logsdail case and improve interpretation of capnography waveform shapes amongst our teams, we have designed a capnography ‘tea trolley’ training programme. This involves 5-10 minute ‘bite sized’ teaching sessions that are provided with tea and cake (or currently an individually wrapped chocolate!) The idea is that the training is taken to the team in the workplace, using available time during the normal working day to spread the message. Our aim is that everyone involved in the care of patients dependent on an artificial airway is able to interpret the capnography trace and feels empowered to speak up if they are concerned.

The training works on a fairly straightforward concept: a theatre trolley is set up with teaching resources on the top and a pot of tea and chocolates below. We then move from theatre to theatre, using one member of the training team to relieve the anaesthetist and anaesthetic assistant at an appropriate point mid-case, and the other members of the training team to deliver the capnography teaching in the anaesthetic room. We also take the ‘tea trolley’ to the Intensive Care Unit (ICU) and Post Anaesthetic Care Unit (PACU), delivering the training multiple times over several weeks in order to train as many members of staff as possible. We have found that afternoons tend to work best in operating theatres and ICU, and mornings best in PACU.

The training is simple - capnography trace shapes are likened to different hats and caps: a top hat is perfect, nice and square, with straight sides and a flat top, and shows that ventilation is occurring through a patent airway; an Ascot hat (like a lady might wear to the races) is still okay, with straight sides and the characteristic upslope on top, showing air ‘going in and out’ through a patent airway, albeit it with some obstruction due to bronchospasm. Then there are the two ‘bad’ traces which should prompt immediate attention by the team: the dunce’s hat, triangular and spikey, suggestive of a leak around the airway (acceptable if an uncuffed paediatric tracheal tube is in use but otherwise a cause for concern); and the very worrying situation of ‘no hat’ – a flat trace. This flat trace should first prompt active exclusion of oesophageal intubation, and following that consideration of a blocked, kinked, or displaced tracheal tube, failure of ventilation, or blocked, kinked, or disconnected capnography tubing. Following the shape identification, it is emphasised that even in a cardiac arrest with CPR ongoing, a capnography trace should still be seen although it may be attenuated in shape and size.

To encourage engagement and participation and to make the teaching fun, we use real hats, worn by our training team or any willing participants, as a visual reminder of the shapes, and with the added bonus of silly photo opportunities. We emphasise that “Posh hats are best in Bath” to remind staff that they should see a row of top hats or Ascot hats at all times. We also use an adapted set of playing cards for a quick-fire round of shape identification for the four different trace shapes. The training package is designed to suit the whole team, from student nurses up to Professors of Anaesthesia, so it is deliberately not complicated. However, to keep the keener anaesthetist involved we have some ‘advanced’ questions and traces, designed to prompt a deeper discussion if and when time allows.

Ninety-eight staff in our hospital have participated in this training so far, with all members of the team actively engaging and with excellent feedback. We have found that training together as a multidisciplinary team has helped to flatten our team hierarchy, has been good for teamwork and is great fun! When a tracheostomy became displaced on the ICU overnight last week, this training was credited by the ICU nurse at the bedside for her actions when the capnography trace disappeared.

Our training package has been uploaded to the RCoA Prevention of future deaths webpage if other groups of postgraduate doctors in training, like us, are interested in running a capnography ‘tea trolley’ teaching programme in their own hospital, they can download all the necessary resources there. If you give it a try, please let us know how you get on!

Dr Victoria Poyntz, Anaesthetic Registrar
Dr Olivia Burke, ACCS anaesthetic trainee
Royal United Hospitals Bath NHS Foundation Trust, Bath

Other members of our team: Tobin Osicki, Rob Penders, James McCulloch, Fiona Kelly