Background and goal of study: Problems with airway management are a leading cause of anaesthesia-related morbidity and mortality.1 Numbers of major airway complications revealed by the 4th National Audit Project2 are alarming, but we still do not know how to decrease airway complications. Relating to the concept of accumulation of marginal gains3 our study tests the hypothesis that the sum of effects that result from changes to institutional airway management strategies and from airway management teaching will lower the total number of airway incidents substantially.

Material and methods: The study is a prospective interventional trial. In the first phase we prospectively scrutinised all major and minor airway incidents occurring at the anaesthesia department of the University Hospital Bern during 2 months. We specifically included minor incidents as precursors of major incidents (Swiss Cheese Model).4 After analysis of the recorded incidents we now implement changes to the institutional airway management strategies and teach specific aspects of airway management. This will be followed by another period of prospective recording of all airway incidents to evaluate if airway management was improved. 

Results and discussion: During the 2 months of phase 1, 3681 cases of airway management were screened. 11 cases were missed, but the remaining 3670 cases were analysed. 574 anaesthesia cases (15.6%) involved at least one major or minor airway management-related incident. Out of these patients 187 presented more than one incident, leading to a total of 830 incidents. The most common incidents were difficult bag mask ventilation (24.4%), need for several attempts to secure the airway (20.9%), Cormack-Lehane grade ≥3 (18.3%), hypoxia (17.8%), failed tube advancement (11.0%) and oesophageal intubation (8.2%). 

Conclusion: Our study shows that major or minor airway management-related incidents occur in over 15% of anaesthesia cases. Based on these data we are implementing a “package” of changes to institutional airway management strategies and teach aspects of airway management. The follow-up phase in April-May 2016 will show whether this “package” can improve airway management and thereby improve patient safety. First follow-up data will be shown at  the ESA.
	
References:
1.	Peterson et al. Anesthesiology 2005;103:33-9
2.	Cook et al. Br J Anaesth 2011;106:617-31
3.	Durrand et al. Anaesthesia 2014;69:403-6
4.	Reason. BMJ 2000;320:768-70

PAPAYA: Prospective Assessment Project on AirwaY management in Anaesthesia - improving airway management and patient safety through optimisation of airway management strategies