SummaryIn aviation, the sterile cockpit rule prohibits non-essential activities during critical phases of flight, takeoff and landing, phases analogous to induction of, and emergence from, anaesthesia. We studied distraction during 30 anaesthetic inductions, maintenances and emergences. Mean (SD) noise during emergence (58.3 (6.2) dB) was higher than during induction (46.4 (4.3) dB) and maintenance (52 (4.5) dB; p < 0.001). Sudden loud noises, greater than 70 dB, occurred more frequently at emergence (occurring 34 times) than at induction (occurring nine times) or maintenance (occurring 13 times). (93%) emergences. These data demonstrate increased distraction during emergence compared with other phases of anaesthesia. Recognising and minimising distraction should improve patient safety. Applying aviation's sterile cockpit rule may be a useful addition to our clinical practice.

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SummaryAviation's 'sterile cockpit' rule holds that distractions on the flight deck should be kept at a minimum during critical phases of flight. To assess current practice at comparable points during obstetric regional anaesthesia, we measured ambient noise and distracting events during 30 caesarean sections in three phases: during establishment of regional anaesthesia; during testing of regional blockade; and after delivery of the fetal head. Mean (SD) noise levels were 62.5 (3.9) dB during establishment of blockade, 63.9 (4.1) dB during testing and 66.8 (5.0) dB after delivery (p < 0.001). The median rates of sudden, loud (> 70 dB) noises, non-clinical conversations and numbers of staff present in the operating theatre increased during each of the three phases. Conversely, entrances into, and exits from, theatre per minute were highest during establishment of regional anaesthesia and decreased over the subsequent two time periods (p < 0.001).

SummaryWe observed practice during transfer of 80 patients from anaesthetic room to operating theatre, to determine the duration of apnoea and the time without monitoring during the transfer process. Median (IQR [range]) time from disconnection of the breathing system in the anaesthetic room to the first breath in theatre was 54 (44-65 [27-196]) s, and from disconnection of the pulse oximetry probe to the first reading in theatre was 90 (74-103 [44-182]) s. In four patients (5%) arterial oxygen saturation fell to 94%, with the greatest desaturation observed 11%. The transfer process may represent a window of opportunity for the occurrence of harm or the first step in a chain of events leading to harm, and is difficult to justify on patient safety grounds. In the United Kingdom it is common practice to anaesthetise patients in the anaesthetic room before transfer to the operating theatre. During transfer, patients tend to be neither monitored nor their lungs ventilated. This practice contrasts with other countries including the United States of America, Canada and Australia, where anaesthesia is routinely induced in the operating theatre. This issue has been discussed in the literature in general correspondence and editorials [1-3], but we are not aware of any studies measuring anaesthetic transfer times or adverse incidents relating to transfer. Our aims were to determine how long patients are unmonitored and apnoeic during transfer from the anaesthetic room to the operating theatre, and to record any adverse outcomes during this period. MethodsLocal Research Ethics Committee approval was obtained to observe routine staff practice during transfer of patients from anaesthetic room to operating theatre. We collected data for 80 cases, over a 4-month period. All cases were adult inpatients, of ASA physical status 1-3, undergoing induction of general anaesthesia in the anaesthetic room. After induction, patients were disconnected from monitoring and the breathing system, wheeled into theatre on a trolley, and transferred by slide to the operating table. Patients were followed from the anaesthetic room until fully monitored and their lungs ventilated in theatre. Principal measurements were the time from disconnection of the breathing system until the first breath in theatre, and the time from disconnection of the pulse oximetry probe until the first reading in theatre. We also noted the extent of pre-oxygenation (formal: ‡ 3 min via a tight fitting facemask or ‡ 4 vital capacity breaths; informal: any attempt at pre-oxygenation not fulfilling formal criteria; or none), whether the patient was on the trolley or the operating table when the first breath in theatre was given, and whether the patients' airways were managed using laryngeal mask airways or tracheal tubes. The theatre staff were unaware of the nature of the study. We asked permission to be present in the anaesthetic room and observe the beginning of each case and then leave, explaining that the nature of the study precluded revealing exactly what we were ob...

Knowing how the body reacts to the presence of pathogens allows healthcare professionals to make informed decisions about what action to take in caring for the child with fever. A raised body temperature raises the metabolic rate and makes the immune response more efficient. It also stimulates naturally occurring anti-pyretics but can also have harmful effects. Careful monitoring based on risk of serious illness is recommended in new guidelines on the management of feverish illness in young children provide (National Institute of Health and Clinical Excellence (NICE 2007), which also provide an opportunity for standardising fever management.

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Assessment is a fundamental nursing skill that underpins decisions about interventions and priorities in care delivery. Rather than the holistic, individualised approach envisaged in the nursing process, nursing assessment of the sick child in hospital appears to focus mainly on quantitative data and preventing clinical failures. In this article, Carper's (1978) four 'patterns of knowing in nursing' are used to illustrate how assessment could be broadened to better inform nurses' decision making and to make child and family-centred care more of a reality.