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thank you for sharing this session after the break on. Please go ahead. Thank you. Thank you. Good morning, everybody. And welcome to the runny cell presentation session. Ronnie was a trainee in, Nor itch for those who don't know him didn't here in 2015. And in that short time we were lucky enough to know here he became a very valuable member of our department. He was an outstanding doctor in every way. And a very fine young man. He's greatly list. It is a huge privilege today for me to check this session in his honor. We have three presenters on four judges. Judges are, um, doctor Kathie Wilkinson, pediatric anesthetists. Doctor Deborah used be intensive. This Chris chart, who is a vascular specialist on Doctor Jeremy course who is an obstetric me suggest, um, so we have a wide range covering most of the basis on our first presented today is Kate Average, who is gained present on her quick project on storage of anesthetic gas. So over to you cage my presentation today on my quality improvement project, which was standardizing storage of anesthetic drugs. I'm going to remove my camera. Just said it doesn't disrupt the slides. Sorry about that. Hopefully you can all see the sides now. So today I'm going to talk about the model that I used for this project on then the project itself. What I hope to achieve on the changes that were suggested on Thean tended benefits of those changes to the way that we start drugs enormous. And see if it is the model of a change that I implemented for this project was the on Do Study Act model, which I'm sending that everyone be familiar with. And I will make reference to throughout this presentation this project came about when I was not restrain me on. I was very nervous about mistaking me drawing up the wrong drug on be causing a drug error on initially feeling that boxes of medication looked very similar and obviously with more experience, drug boxes and drug ampules started to have him less and less similar to me. But that then again, I always to recognize there was a risk off me making a drug hair, uh, on in the literature. There have been mathematical models done. We show that there's a 10% chance of drug error in operations or 12 hours on, even if we don't believe the math on we look a really World. Data on the NAP five study showed that or five of the 17 cases of awareness that had reported those would do two drugs errors on and just below. I have shown some boxes as an example off that consultant gave me. Now I'm in a step tricks where sucks Methionine was given instead of oxytocin just due to possibly have similar, the boxes were in the fridge on again. Another example I wanted to highlight in reference. This project was a drug area that was raised by the safe and the Seizure Liaison Group, who mentioned that this this case in there update It was a baby who received sodium bicarbonate when they were very unwell, with a metabolic acidosis on their blood gas. But sadly, instead of receiving the sodium bicarbonate, the baby was given sodium nitrate, which had, you know, severe implications. Um, and there was also instances when I was at work where I felt it took longer than it should to find a drug, either myself trying to find or someone else on. I thought about those inefficiencies on when I looked at the drug cupboards in our emergency hitters six and seven at the North Can orange on the last, were slightly different, just in where the antibiotics were kept. And that meant the show's had different drugs on. So I did some more research on. But there was other examples off improvement projects that have been done in other hospitals on which inspired this project, eh? So looking through those, I think a month with the plan off how to approach this project. So what I decided to try and do was assess the degree of variation within our first See if it's a drug cupboards on also the time taken to find a drug as a potential implications off. They're not being standardized. Drug storage on the really aim of this was to try and reduce drug areas, which I really mentioned, but also, anyway, stitch of drugs through drugs being stored in various locations that could be multiple boxes opened on. There's always a potential, then that some of those could go out of date. All there were there could be unnecessary drugs kept in the coverage that cluster the cupboards. I mean that stocking them could be more difficult on. I'm rotating stock on also, as I mentioned previously, just dialing totally to reduce inefficiencies and potential developing treatment if it was taking a while to find a drug. So what did I actually do? Well, I time staff to find an emergency drug from the emergency it cupboards on that was asking them to start at the doorway off the anesthetic room until the moment where they found the drug, ordered it it to the drugs within the cupboards against the current stop list and then look to the evidence to try and come up with a more comprehensive stock list. That was up to date with our clinical practice. And that involves looking at the national Essential Anesthesia Rug list, which I will mention, um and then also formed a m d t. To look at that list on rationalize the drugs that were on there. What should actually be kept in our on drug covered it's and that included are specialists pharmacist for Nolan. He was able to give us information about which drugs were expiring on going on being wasted, and then also I wanted to matron and only peas who were essentially making sure that this train change could actually be achieved. A Z well, as our as well as an anesthetic consultants who could ensure that the list was 50 purpose. So the results it took, on average, 10.6 seconds for stuff to find an emergency drug on that was arranged between 5.4 seconds to 22.6 seconds on do the audit. The raw data is on the right, but I've summarized it in a smaller table blown up so we can see that the stock list discrepancies there. There's quite a few in both. It is so 11 and 12, respectively. On In addition, there was additional drugs in the cupboards, which included your phentermine etomidate near stick me on its own and program Paris seen on out of danger drugs. There was three boxes off in a left. So, as I mentioned, I decided to have a look at the evidence face for trying to rationalize what drugs should be kept in the covered on. Looking at the National Anderson essential Anisette at this easier drug list I've taken the definition is directly from their report on they have a list of essential medications, which I thought would be a good starting point. So there's a defined by the who on then necessary drugs, which are those off the essential, which there is no alternative critical being drugs that are both necessary and of under bought. A shortage on priority Indication refers to the drugs that in times of shortage, need to be reserved until we know we can get interior supply on that. Just summarize that table there cases of used to anybody who hasn't heard of it just so we could learn about that today on so off those that were there was no Walter knitted Be a weather, some adrenaline Freemason ill naloxone on magnesium on golf, Those which are necessary so vulnerable to shortage. We have adrenalin on do magnesium on those we should be prioritized in case of shortage until the spy could be guaranteed. Waas adrenaline know adrenaline on beautiful. So I just thought I in touch on that on this was helpful when we had our MDT meetings to review the results, which I will go through in just a second. Um, the reviewing of those on but keep in mind in the MG T. What drugs actually should be on the stock list on dwon't? And we learned from that. Well, the average time taken to find a drug was short, so it was 10 seconds on in comparison to the timing's. I found in the literature that we could be up to 25 seconds on average, so we did well there. But our range was up to 22 seconds, suggesting there was some room for improvement on the order. It showed that there was large variability and how we're storing drugs on the discrepancy with our stock list on but potential to reduce waste on from the MDT discussion, we tried to get to the bottom off. Why that might be on the stock list. Not being up to date with medical practice was one of the main reasons for why, for example, the only piece suggested that the stock in the comments wasn't always the same as what the list suggested should be. We will agree that by removing some of the unnecessary drugs we could decaf to the cupboards on by makes talking them easier on also ensure the drugs that didn't need to be in there were in there and in date. So we suggested a change, which was a new standard stock list. But also we proposed a new covered lay out on that was with the emergency drugs kept on a separate shelf. Firstly, to allow the only piece to prioritize restocking the emergency drugs on day. And secondly, because it could help avoid a scenario like in the example I gave where baby the baby was given sodium nitrate instead of sodium bicarbonate on. Although that wouldn't happen with our stock list, it's still removes that potential on recognizes that sometimes people going into these cupboards are not familiar with all of the drugs within them. Um, Andi the Thirdly, we also looked at which drugs could be removed on dept. In the drug store to just help decrease her so you can see those on the list there on. Finally, the process can be repeated to make sure that any changes have been made actually accomplish what we hope they would on, but would involve again repeating repeating the order. It's timing staff re examining the evidence on then looking at those results within our empty T meetings to make sure that the stock list is fit. The purpose on that is the end off my presentation. Thank you for listening. I welcome any comments, thoughts, questions on dust for reference. I've included all the reference is used for this presentation. Thank you. Thank you, Kate. Now, our next presentation is doctors are a brown regarding improving day case Analgesia at an N u h. Thank you. So, uh, go ahead. I'll I would welcome My name is to celebrate I'm on the clinical feather than on the same team. Reports a Norfolk analogy Last hospital and together with Doctor Morris, we've been doing a project looking at improving Jeezy A for headache a sagittal patients. You might talk today. I will give some background to the project. Talk about what are color protocal is the review of all covered practice in the outcome of that go through pain school systems in general on what we're going to be doing. Teo Improving vaginal juicy for a day case. Surgical patients About two thirds of surgical admissions within the NHS in England are being undertaken. It's day cases in 2019. Academy of Medical Royal College is advised that day surgery should be the default, a zits less disruptive for patients and also on juices, the risk of hospital acquired infections. This was written before because 90 lbs in it say, perhaps even more so as it reduces the risk of hospital hard place for 90. But also given the pores in Are Elective program, day surgery may well be very important in terms of recovery. The day surgery delivery pack suggests that there should be established protocols for perioperative analgesia. The analgesia should be multimodal. The choice of drugs should try in the juice or avoid using drugs that are increase the risk of postoperative nausea. Vomiting, which causes delays in recovery and also will influence discharge from hospital in terms of using rescue allergies. Easier and ideally, this should be short acting opioids as well. Adequate pain control is part of the nurse lead discharge. Carteris. So what is our coverage critical? So what? Arrival in recovery our patients are assessed as part of that assessment. They're paying a scored on the four point scale was there is no pain and three is severe. Okay, on that should trigger in action either Teo reassess them or to get him on allergy Easier on dissent. Sample Unaudited protocol was actually published in the British Association of Day Surgery Handbook, and this is what we should be doing at the Norco Can Knowledge Hospital in order to see what are covering. Practice is, I looked at the notes of 19 adult daycares patients. Over the course of four days. You had either a general anesthetic or private plane spiell any surgical procedure my collected following data, particularly looking at the highest pain schoolwork. You come free the length of stay in recovery, Any allergies, a little e were given the dose in the type and whether there was a delay in recovery or whether I had another anti surprised that mission. They're waas adequate intraoperative analgesia majority of patients is 15 of the 19. Their highest pain score was accorded to zero, but in for the patients, they did school on three of those patients. The highest paid school was, too. These patients stayed in recovery longer just to be expected, and they average like the same 78 minutes. None of them recorded any postoperative people's. You vomited looking at the patients that did receive allergies. Um, one in recovery friends. The three I mentioned that had the highest pain schools recorded. We're delayed in recovery. Do to pay in terms of whether we felt that the protocol was followed. It wasn't particularly clear on actually a patient with the pain schools zero received her settle. I couldn't find any documentation is still wide on the patient who had been in the office or Skip 80. Saved then with the grounds is intravenous move anus. Well, as until process it'll but no other. All longer acting. Opiate, the patient who had a laparoscopic credit cystectomy in Bold on had on untis a pated admission and spent one night and night in hospital. So there were several points raised. Looking at that information and also having spoken to recover of stuff. There was some variation between any citizen terms of what was prescribed for POSTOP manage easier on this may be related Teo the procedure that the patient had speaking to the recovery staff and showing them the flow charts. They weren't particularly familiar with that. Some of them had never seen it before on by couldn't find any documentation of said flow chart in recovery over on the Internet. The school insistence used by the recovery stuff was variable. Some of them used the four point system. Others used a 11 point system and then interpreted that in terms of the four point system to document it only chart the starts that look after day. Case. Patients also look up in patients on they recovered in the same area. So potentially there isn't buried experience with the King after day case. Surgical patients, which might influence what they do in terms of administering and Jeezy a on the only allow patient valuable in recovery was arm off on having spoken to you to recovery stuff. I think there was a feeling that they affair to wait on so that patients could have something else award on preparing to give IV fentanyl as their first option and then letting them have the option when they get to the world. So in terms of scene pain scores that were being used, they're the level rating scale. So that corresponds to the 4.7. We'd we use Onda 11 point miracle pain rating scale, both validated. You don't actually scores, which are well known. They do have their problems on do a recent systematic with you, published in the British General anesthesia this month. One of their conclusions. But it was a miracle writing scale cutoff point's used by professionals don't actually reflect the patient's desire for algesia. So what might be better? Perhaps using something such as a functional pain assessment score, which might be a bit more objective and tendon a tell. I found that this actually correlates well with the new Miracle and reaching school at the extremes, but actually might be a slightly better way of assessing pain in the middle range is so the assessment of mild or moderate pain a zit might be easier for, uh, staff on patient to differentiate between the two as the pain stops them from performing particular activities. So how can we improve the allergies either Friday or a surgical patients? So perhaps patient preparation from to management of the expectations would replace to start counseling the patient and letting them know that Teo expect some discomfort afterwards, and that's normal, but it should be able to pay. Um, that's a level that they're able to manage at home on five. Ministering the radio on or jails. Yeah. Um perhaps in recovery, using a different method of assessing pain, which might be easier for precious to understand. And then might me more objective in terms of interpreting back to the minister and Jesus by stuff looking occupations and also having, um, off the alternative on Jesus available in recovery. Second, dihydrocodein and codeine available so that if patients are given intravenous pencil, then they were also giving a longer acting. We cope. Yet alongside that, this might take a bit of a change in terms of thinking about looking after day case patients rather than in patients on gaps. Actually looking after day case. Surgical patient does have a slightly different mindset in that respect. So education is fort would be necessary nose. To make those changes to assist in that we proposed update the day case pain assessment. Rachel, as you see on screen to include a functional assessment of pain. So assessing whether they have paid it restil not. Do they have pain with normal rudiment gentle movement? Or are they unable to leave because they're in pain? And Comey Deep Brady's Can they cost? Can they be destructive food pain on By assessing those particular factors then that might help guide what type of I'm geez, ear is given. So whether that is car settle most a little on opiates or fentanyl on a plate and then repeating the mental list later. So in summary at uncontrolled pain is the significant cause. If delays staying, recovery the late destruction hospital on gun anticipated overnight admission to the hospital you need, I mentioned. Pain assessment does actually have militant correlation with patients need from Jesus. So perhaps a better way of assessing patients pain is using the Functional Pain Assessment School. We proposed to update the day case and easier flow chart to include a functional pain assessment. Ease of the references. Unused. Thank you very much for listening on. Now it's time for some questions, and so shall we move swiftly onto you, Chris already? I think so. Yet he was going to talk to us today about a less airway management. They I'm Chris. I wanna be anesthetic CT one training. He's up in kings Lynn and I'm presenting today and order we've undertaken locally, which was looking at our compliance. Our airway intervention into cardiac arrest with the new air less guidance. Sorry. My videos. Not working. PowerPoint keeps crashing when I when I'm trying to record video with it. So it's my weight only I'm afraid of Democrats in there. It's like you are kind of said A monkey doesn't matter which we use linked to each other. It's only been a fine. You don't have to do it, but it's just looking. And it's a couple of questions, too, or you do a cardiac arrests from an airway point of view, we're not gonna do anything with the data. Is there gonna be dilated? It's maybe just for a bit of fire and German interest. Really Surface things. First, where did we decide to go on? State disability will already some from a new ls guidance, which came I made 2021. Now they weren't a huge amount of changes for those familiar with the old guidance. But change the typical mean you've heard under the Airway Mental. A shin section really consisted of tightening up tighter stipulations around those. He should be intubating and you can see it. It's saying that those in probably should be intubating of those were there successfully too, baby 95% within two attempts on there from stopping CPR to recommending it should be no more than five seconds supposed to last a lifetime partner. Par. So with this sleep, D L0 V o should be used as consistent with the agent by guidelines, capnographer should be used now very, very surprisingly, really surprising to me, and trust was actually we don't actually know how compliant we are with these guidelines. We don't actually know how good we are, and it's something that really hasn't really been looked into. So we thought we would look at it now the side or attention to take this? Or did we also wanted to know as a cohort of any city is what we were doing from an airway point into being. Now every needs it is. Every abreast I I've seen seems to do something slightly differently with a different rationale behind you. Whether the physiological would be pressured and cardia rescue stability or iris or getting to be more stable best litter to avoid another S I for airway protection, every moment doesn't seem to be either. Any consensus is to, you know, if it'll work, the best airway is, and it also doesn't seem to be any literature out there looking at what exactly we are doing in an in hospital. I'm not kind of want to wear the airways to study. Now they're better company CAVEATS to this, But this was a big study about 9000 patients with out of hospital cardiac arrests with a paramedic cohort. But what he was looking at was the i Jobert is an et tube doing cardiac arrest. Looking of that, that the outcome's and the main conclusions and to cut a very long story short. The short notice have been different since five of age Progressive Station of Respiration, but it did show a significant difference in successfully. I feel what's acceptable rating to attempt quicker and need teach you about. They were lost unintentionally more and that really big question. Is that how it's traveling because his entire spring practice and should be taking anything from this? But before we make any improvement, we kind of need to know where we are at the moment. So the safe side, but scientists in aside from motivated little bit was to look at or what are we doing on, and it's Benny started Mr. We're going from here? How do we quickly sordid? But we'll talk about in hospital. Cardiac arrest. Um, getting clear day in the evening. It's from September to December, 2021 on the Internet. For your best, we asked already pay in a desperate tend to a cheese Buyers would in a trust, trust or anything. Just give us an unbiased answer. We ask the page completely opposed to last for more shots, a whole host of questions. I'm a type of airway type of disco, but also, how have a long it took to get the airway You numbers where data was calculated on analyzed in the event that we couldn't get the TB or DPP. Remember, we couldn't get a hold of the 80 people for a reason or another. We get up in the system rectally. Now I should stimulated this point that what we did is we are for best. Guess is when it came to time. And this is a huge future, usually imitation. But we don't. It was not Craftmatic to be asking already. Please go on any statistical anyone else when you're resting to be whipping out, stop working to be timing So what we have asked is very best guess in the guards the timing. And if we weren't hundreds, actually basically ask the question about it more or less than five seconds with something CPR to be committed on be used. That almost binary body. There's a huge source of bites and huge stops of Era a Z. I say we felt that was the most problematic way around this. So how did you know our standards without the 95% success with in within two attempts was reasonable. Remember 97 that they should have that sensation of CPR to be commencement 19 syndicators. Unsurprisingly, we wanted every single we teach. You could work with hepatitis C and see how much keeping with what you're saying no trace on place without anything that that would would be unacceptable. So moving on to our results on we have 31 cardiac arrest room this time which was fairly evenly split between any of the wards before coma righty you on. We were slightly eat each evening. Clients department, it turns out, but actually a fairly even split now 100% of our teachers were placed within the two attempts which is actually moving our jobs, which I don't think we're quite expected and certainly good against the airways to findings about 92% or one case. It wasn't exactly basically, I don't have to be converted to any teaching now when it comes to the time that CPR was stopped for again. When it comes to achieve, a 40 didn't past this standard. We had an average time of 8.3 seconds, then near pass rate or any a success rate of 83%. Now, some element of bias in this because we don't have a strong know with the breasts. Four cases to go longer than five seconds on one of those waas 120 seconds, or are results I started. Just give him on data stable before people. Actually about four case, I should say so many had at the time of zero seconds are you? They were in treating our CPR. We don't in progress when it comes to a nice job. However, hundreds in today's replaced I'm in essence five seconds, with overall success rate of 90% on average time of that, replaced with a 4.8 seconds 20 just inside, but but it passed them to this. Unfortunately, we didn't manage to professional about me teaching with entitled C o T. One case. Fortunately, equipment failure where the entitled Seen it was connected turned on. But it didn't pick up a reading. I'm so I knew it was in 94% of my cheeks were where I'm confirmed with entitled. So what to make of these results? Or I don't appear to be quicker to insert, which perhaps his unsurprising and again it's with the airways to study now, as I say, that has to be taken with a little bit of a pinch of. So I don't think that that sense of them can be taken as concrete only mind by that we've been looted to earlier. That one case that that took 100 20 seconds perhaps doesn't injustice to be teaching placements when you think about four cases 07, which was brutal exactly the same as the I Joe bedroom, and we only have 30 cases here. I think there's not enough. No, not not patient is here to be to join any clear conclusions here, but as I say it. But no, I don't remember if I said it was a It's a very nice drug argument, but you struggled toward the comma, I think. But I think I've been taking those concrete from this order. Bit of equipment. This was our own issue, and the feedback we got from our arrest was a little over five minutes to get a new entitlement, er, to confirm the chicken placement. And in that time, there's a lot of burning and a nice thing with anesthetics shoulder, which was in but without without that confirmation trace. And I guess where I think which is particularly meant by the department, is if that was you, what would you do? And how much redundancy do you have in your system now? It turns out we didn't have any really adult of this. We're not taking two entitled to 20 minutes. Arrests and ovaries are stable. If you're getting defect with integrated 02 recordings now, what's that? Obviously gives us a lot of redundancy from right From a cdot point of view, it does make the question. Is that still what else in our system needs more? You know, more more back up. But I guess for a man from from other departments looking in. I think this is one of our biggest to take messages. One became it'd be one to convey, which is that if it's happened to you, has it ever happened to you? And if it did happen to you, what would you do on what is your fallback plan? Um, I think you wouldn't combine that, but I think, But then we were very happy. But where do we go from here now? First me. I mean, there's a team what we're looking to build on missing a lot of research front. So we're looking to try and look into this with Ben. Compared was great night in your admissions and distracted Neurological outcomes. Published this on Do A On what? I'm going to claim it to be anywhere near his scale of their wares to your immunity airways. Too kind of study from working as a nurse, but level, um well, I also really want people to do is to think about what they do and arrested why? And as I believe it's a lot of people do lots of different things for lots of reasons on I think what I really want wasn't covered, reflection and to ask people, Why do you do it? It's it's physiological, or is it easier or is it habit on? I think if we can get people reflection that. But I'm very, very happy and that's me done. I'm a big thank you to hold, always run into with out there helping support was simply would have been done. But about from that anyone, any questions, I'll be more than happy to answer them and technology mentioned, I'll see if I can get those are serving lunch because I was up very much. Well, they can very much Chris for another, just in talk to so three very good presentations, all very, very relevant to our daily practice. All cover aspects of our practice that we think about on the regular basis. We are going to live questions to about 3 to 5 minutes. Reach candidate. They're all ready. Had to be questioned on D that you take two questions. Each one is going to take two questions Wrong. The judges on We'll start. We'll go through an order so we'll start with Zarah on Zar. I'm going to hand you over to Doctor cause Sharp For your first question, no. Owns our thank you very much for your presentation on the question I had was in the four patients who have very degrees of analgesia recovery. What did they receive in theatre? Was there anything in terms of an inch easy, I think in terms of what they received in theater, Um, all of them receive fence. No, on. I don't have that information directly to hand, but in terms of what they always see Ventolin very in doses. Some of them west Want any asleep reading? Um um mostly the relating roberta. Stop it. Cholecystectomy wasn't, but certainly she waas she did receive it. Image beta dose of fentanyl. Um, was there any particular similarities between what I had? No, particularly, um, say they both. Both the lady. You have the lack of scopic cholecystectomy and we don't even have the knee. Arthroscopy also got morphine on down. Still worried or so, Actually, they did get multimodal on algesia on perhaps the reason why they were the ones that had, um hi. Painfuls was just for surgical reasons. Um, this the left coli was actually quite a long one in comparison to other luxuries. And from a surgical point of view, it looked like it was a particularly difficult one. Okay, thank you very much. Um, then thank you. On over to Dr Me Speak was going to ask you a question. Getting thank you. Sorry for you talk. Um, one of the things you identified was that some of the recovery staff didn't necessarily know about the protocols that were in place. I just wondered what to what extent were you involved with the clinical nurse educators to recovery when you did the project, Did you find out a little bit about the teaching they were delivering or what? From the teaching. The nurses are taken away. I have since spoken Teo, the nurse educators on I think in terms of going on from here and making some improvements, that certainly will be my direction. Speaking to them and actually going through. It's, um, what I found on day two, perhaps, and changes. I might like to make a spoken to them about changing the flow chart and including a functional pain assessment. And actually, they were quite keen to be involved with That change may quite like the idea of using a we're looking at and whether the patient is able to do certain things. Um, also because that feeds into part of their assessment and seeing whether patients were able to a A commands so that serves a difference, like a different purpose. But they felt it was a better way of looking at pain rather than a number. And so, in terms of whether I went to even first speak to them. And I understand what that will ought to be, that the level of knowledge that they have. No, I haven't done that it at the time. But certainly that's something that I'm going to look at on. But try and improve things on, goes and goes through them in order to educate the started medical. Okay, lovely. Thank you. I hope that goes well, thank you very much. So in the interesting fair so that everybody gets the same questions. I think we'll go up Doctor Hardy Now, in the meantime, if anybody who's listening wants to put a question to the chat, then if this time we'll put those questions to the presenters a swell. So, uh, now over to Dr Wilkinson, he was going to ask the question to Doctor Hardy. I, Chris really like presentation and light. Sure and buried QR code as well. So hospitals very quite a bit is to availability of senior people to manage the airway. Um, have you had to think about what hospital should really do? Um, should they be establishing an airway plan in recess? Um, just using research council guidelines as an indicator of quality. What do you think the honest answer is? I don't know. I don't think anyone really knows the answer to that. And I think this kind of throws they airway doing cardiac arrested it a hugely kind of, though I say a controversial area, Um, hence the airways to study. I'm and I think we've kind of gotten out from a pretty hospital population. But in hospital level, I don't think, but there is a right and wrong, and I don't think there is an algorithm that could be applied. I think if you extrapolate the airways to study, that is a very strong argument to be saying that a nine Joe should be first line. But obviously that was with the paramedic cohort. His first part success rate during inspiration was 73% on. But we've shown that any statistic not be necessary On the arrest him of the curator on mostly ct one C t two level at least from the data we collected on we're getting around 83. I think it was first possible, too. Isn't know to pass success rate, So I think that's gonna be taken with the pinch of salt. So be honest. Answer is no. I don't think there is an algorithm that could be applied. And I don't think there is an airway plan. I think you've got to rely on any statistic individuals to read the evidence and no escape was that And no, that's drink some weaknesses. But I do think that with a mask and a half why we did the audit. Why do you think the airways to study? Really does. But the Catamounts, a pigeon to movie, does take some questions as they are with just integrating arrests because we can rock him because we should. Okay, thanks very much on your second question is from Doctor easily. Thank you. Chris must to see, um, in terms of compressed. Did you look at the cause is of the cardiac arrest when you were looking at the airway choices off the anesthetists. I mean, I know you mentioned you had one really outlier 120 seconds. You know, in my head, if that been a hypoc sick arrest and you want that patient really well ventilated, actually take 120 seconds for difficult intubation might be appropriate. If it's been a reasonable Janica dread arrest, actually hanging out and putting on eye gel in and getting on with it might have been a more appropriate. So is that something you looked at? Some sort of out. It's not something we looked at as part of this order it. But we have collected data on that, something that we're going to look at as part of the research project. I think a some unofficial results. What we did find was at once which weren't mean we had one, which was a clear or fairly clear hypoxic course, and they were achieved. Unfortunate was also the one. We didn't have the entitled trace, but I think people were using special, mostly or more towards wet where airway was a concern. Um, but but no I don't have that data immediately to hand. Thank you. Oh, geez. My own meat there. Thank you very much indeed, Christs. So we'll go over now. Teo. Kate, on your first question is going to be from doctor course a day pen to fill your presentation. Paul Barker did something very similar about 5 10 years ago on D. Got a good list of drugs sorted, had it all all kind of standard eyes and slips with time. So you know different. Only he's going get a box of something rather than one and a two year old, and they stays in the cupboard. And when you look in a couple of five, all sorts of unusual things So how you gonna take this forward, and how you going to ensure that that doesn't happen? Who is gonna be responsible for going through the cupboards and removing this extra start for making sure it doesn't happen? Thank you for your question. I hope you can all see and hear me. Eso Firstly, I I actually did review all of pulled barkers. Audit on it. He also presented that so I had access to all of his work on his slides on. I could see it been many years since the the project had been taken on on. So I chose to approach this in a slightly different way with the more of a quality improvement project. And I totally appreciated that. Actually, what was happening was that this was just being left. And actually, if we look at how the covers of stopped at the North can orange, there's a lot of influence by the particular ODP is that work in that theater at that point in time? So what I try to achieve was by bringing every the stakeholders together in this sort of multi despair. 18 to try and get people who are actually going to be involved in keeping the cupboard stopped have a chance to voice their opinions on after speaking to quite a few oh, DP's they were concerned about change for the sake of change and actually involving them in changing the cupboards is one way that I hope that when we take this forward, it will it will be sort of continued, and it's not just going to be a single project but actually resemble more of that cycle that I described on my slides. I think the second question you asked about is the box is that just arrive in the cupboards? Because, for example, some of the drugs that are in the stock list they remain on our standard store stock list to be stuck on the cupboards because we recognize that on occasion those are asked for Onda Ola, who is our specialist pharmacist in medical management, make sure that those were on the list, but actually that asked for so infrequently that they don't warrant being kept in the cupboards. And in answer to your question of who is responsible for removing those boxes, well, we're all responsible. I think the O. D. P's do stop the cupboards, but they actually frequently need reminding that it's acceptable for them to take boxes out and the open boxes Congar back to the store so that other people can use those ampules actually could end up lying in our cupboards and have the potential to go out of date and contribute to waste, but also just close to the cupboard. I mean, it's incredibly hard to keep well, stops and and use a friendly. I mean, I I find myself doing that quite often. Remaining boxes getting back to the eighties drug so we never use. But I think you probably need to formalize it. Morgue is I don't I think I'm probably fairly unusual amongst all my colleagues, and it's absolutely no. So the second stage of what I've done is I've actually in the process of creating laminates with drugs labels on. They're going to go on the back of the cupboards. It's not very easy for me to explain, but if you were to open the cupboard door now on, look at the shelves. You'll often find the labels for the drugs. They're a fixed to the actual shelf for the front, and we're hoping by putting a laminated laminate at the back with the drugs written on them, it will be very difficult for someone to purposely book Put, for example, of a box of, um, metrozole against ah, line that says a different drug. If that makes sense on then, obviously I'm staying in the trust within a year, but I certainly hope to hand the project onto someone else who will take it forward and continue to be as passionate as I am about trying to get this improved. I have a little bit of OCD myself, but we are expanding. This s so we've got a list on now for the obstetric bitters and trauma theaters. And then the ambition is to try and bring it forward to all the other theaters. But it does involve it needs to involve other OD piece who work in those theatres twos. You can't just have a one size fits or it's about the people. Okay, thank you very, very much. I think you sort of answer the question. That comment that came up in the chat about the fact that in East tests themselves are often very messy on drops. We all need to dig deep on book, look within our own practices. Well, that concludes the questioning. Thank you very, very much to all three of you or absolutely excellent presentations. We've do encourage our data, gets to get another look in the post room. Uh, the results from the presentation, the judging, the presentation's I think will be available. Thank you. Very available at the end of the day on, um, if you, uh, parents gave often have some lunch now, then we are reconvening at 1. 30