Decision making in a ‘cannot‐intubate, cannot‐oxygenate’ scenario. A reply

Jefferson et al. are correct in noting that the reluctance to perform front-of-neck access (FONA) techniques is not solely due to a lack of training. In a similar study, participants undertaking a scenario that immediately followed a FONA-skills session were also delayed by unnecessary actions 1. However, in contrast to Jefferson et al.'s work, all 64 subjects in this study progressed to perform FONA. Apart from earlier training, the difference was the presence of both the emergency equipment and a cognitive aid (laminated flow chart) outlining the required action in the cannot-intubate, cannot-oxygenate (CICO) situation. Several other human factor studies have illustrated that decision making of anaesthesia teams does not occur in isolation but in fact is context specific. In an interview-based follow-up study to the Royal College of Anaesthetists’ 4th National Audit Project (NAP4), human factors contributions were found to have been present in all 12 cases examined 2. A median of 4.5 factors was identified per case with task cognition factors such as fixation on the problem and poor preparation being the most common components. Experienced anaesthetists often rapidly select clinical actions that match the cues they recognise without comparing options 3. The majority of times they are correct, but the downside of this ‘recognition-primed’ decision-making process is a failure to identify rare and unusual circumstances such as the CICO situation. In other words, they become fixated on what usually works 4. In contrast to Jefferson et al., we believe the challenge is not more training to remove psychological barriers but rather how to redesign the environment and the training in concert to support decision making under stressful conditions. Cognitive systems engineering is “an approach to the design of technology, training and processes to manage cognitive complexity in sociotechnical systems”. This approach recognises the importance of other prompts and cues in the environment that can augment training 5. Influencing the behaviour of anaesthetists by redesigning equipment, prompts and training of other staff is increasingly recognised as important. Even simple skills that were once thought to be purely technical such as effective bag-valve-mask ventilation are now identified as requiring complex feedback from multiple cues 6. The source of cues can be recognised by cognitive interviews, observations and decision analysis and designs that improve the visibility of these cues can be created. In the case of the CICO scenario, improving the visibility of cues can aid recognition that the state is indeed the rare, once-in-a-career situation anaesthetists fear. Additional prompts and cues can take many forms such as cognitive aids, arrangement of equipment and encouragement of other staff to speak up if they have concerns 7. We have recently described a cognitive systems engineering approach that identifies the barriers and enablers of the challenging decisions in airway management, such as the decision to transition to FONA 3, 8. This approach identifies opportunities to improve non-technical skills such as decision making by improving the anaesthesia system's design, rather than blaming a failure to act solely on hazardous attitudes or an unwillingness to act. Considering the design of anaesthetic environments beyond just training is crucial to aid decision making in stressful situations such as FONA.