CPDme Blog


The CPDme blog can be a personal CPD diary, a daily balcony to shout to the world, a collaborative workspace of useful information, a political or non-political soapbox, a breaking-news outlet, or a collection of links to share with the world.

Our blog is whatever you want it to be. If you would like to submit an article please use our article submission form. New items show up at the top, you can comment on them or share via social media.

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  • 21 Mar 2013 11:52 PM | Anonymous member (Administrator)

    CPDme are offering you the change to see one of our interactive PDFs that are featured on our CPDme USB Drives. These are available anyone and are priced at only £20. 

    Once downloaded, this document is packed with added features like interactive web guide links and the ability to save or print your work. Need help with reflection? easy, just click help!

    Why not try this FREE document and then upgrade and purchase our CPDme USB drive. For only a one off payment of £20 you get a CPDme Branded Credit card USB drive packed with editable and printable PDF documents that you can click and edit and then either print off or save.

    You can then either upload these to your online CPD portfolio if you are a member of CPDme or print them off and collate in your development portfolio. You dont need to be a member of CPDme to use these documents. CPDme Members get unlimited updates to the USB drive.

    You do however need the adobe free reader to edit and save these documents. Click below to download this FREE adobe reader.


    Download the FREE Adobe Reader Software. To use the interactive features of the CPDme documents, you must be using the latest adobe reader. Please feel free to share this page with friends using the links below.
  • 02 Mar 2013 11:12 PM | Anonymous member
    Prehospital Trauma Symposium

    Ambleside, Cumbria

    On the 22-24 February Mountain Trauma Rescue Services hosted the first Prehospital Trauma Symposium in Ambleside, Cumbria.

    This event consisted of a range of presentations and practical workshops, delivered by experts in their subjects. Friday's theme was remote trauma and rescue, Saturday focused on major incidents and Sunday focused on major trauma.

    The Symposium was for anyone responsible for providing trauma care in a prehospital setting from doctors and paramedics to volunteer rescue services. In addition to learning more about the latest trauma research delegates learnt how multi-agencies deal with trauma victims and also gave those who attended a great networking opportunity.

    A full programme and descriptions of speakers can be found at www.traumasymposium.co.uk. College of Paramedics and Mountain Rescue Teams received a 30% discount on delegate costs.

    This was a fantastic, interactive CPD opportunity set within the beautiful Lake District. Visit our website for further event information http://www.mountaintrauma.co.uk/
  • 20 Feb 2013 10:57 PM | Anonymous member

    ‘Working Differently in the 21st Century Means Learning Differently!’

    by George Lueddeke OCT MEd PhD

    Consultant in Higher and Medical Education

    20th February 2012

    The global Lancet Commission report1 was released in December 2010 and is fast becoming the new Abraham Flexner report (1910)2,’which paved the way for medical/healthcare delivery across the globe in the 20th century.’ The Commission co-chairs, Professor Julio Frenk, dean of Harvard's School of Public Health (formerly Mexico's Minister of Health) and Dr. Lincoln Chen, president of The China Medical Board, commended the book as 'an important work,' which independently complemented their own findings and recommendations. In their view, as an enabling mechanism, the book might help support the implementation of proposed Commission reforms and recommendations.

    In addition, the book has enjoyed considerable support (non-financial) from senior members of the World Health Organization (WHO) and the Global Health Workforce Alliance (GHWA).Most recently, it was recommended by Dr. Susan Skochelak, Vice President of Medical Education at the American Medical Association (AMA). 

    The premise for the book is quite simple: in terms of health and social care, we need to learn to work differently in the developed, underdeveloped and the developing worlds in this decade and beyond and that requires new approaches to education and training. Knowing what we know with c 5.7 billion in developing nations and c. 1.3 billion in the developed and underdeveloped, we cannot go on as if we are still in the 20th century.

    My main argument is that if we want people to function differently and more effectively - with greater compassion, empathy, commitment, competence, thoughtfulness, and teamworking, - then they need to be educated and trained differently.3

    Things would need to change considerably in medical/healthcare education at undergraduate (UG), postgraduate (PG) and continuing professional development (CPD) levels, including, inter alia:

    • aligning competencies to population health needs– ensuring that student and trainee knowledge, skills and attitudes match workforce expectations, now and in the more immediate future (e.g., care of the young and elderly and addressing the rise of non-communicable diseases);
    • balancing prevention and curative measures in medical/healthcare (minimising the notion of ‘a pill for every ill’) and ensuring that consultations take a more holistic or ‘whole person’ approach, including early diagnosis and intervention;
    • optimising interprofessional teamworking at undergraduate and postgraduate levels that  flattens hierarchies, empowers people, and reduces, ideally eliminates, professional fragmentation;
    • strengthening training in hospitals and the community, thereby decreasing waiting times (e.g. A&E, surgery), improving treatments of the elderly and increasing investments in infrastructure - polyclinics, community health and well-being centres, care home visits and bringing back home visits-24/7). 

    Since the book focuses on current and future issues facing medical/healthcare education in both the developed and developing worlds, it may be a useful catalyst for discussion and reference for both practitioners and students-perhaps as a core or supplementary text for medical, nursing and other allied health students.

    The book also raises awareness about the growing importance of public and global health, primary health care and the need for greater collaboration among the developed, underdeveloped and the developing worlds.

    Several chapters in the book are concerned with developing competency-based frameworks and curricula, particularly 'with a view to innovation in skill mix and clinical roles which is crucial to achieving a more efficient and flexible workforce.'4,

    Dr. Richard Horton, a UK physician, editor-in-chief of the US-based The Lancet and a Lancet Commissioner, calls for a ‘re-moralising’ of the healthcare system, one which builds ‘a new kind of professionalism -patient-centred, interprofessional and team-based,’ and one that rises above the ‘rigid and damaging tribalism that afflicts the professions today.’1

    Indeed, Dr. Ruth Collins-Nakai, former Chair of the Canadian Medical Association (CMA) and now Chair of the Canadian Medical Foundation, echoes Dr Horton’s observations, envisaging a type of leadership that ‘would be courageous enough to act in the best interests of the populations they serve rather than the best interests of business or economics.’3

    In terms of health systems, including the training of health professionals, Dr. Margaret Chan, director-general at WHO, observes  there is a need to ‘get back to basics’ and a ‘shift to thrift’ ;‘a thirst for efficiency and an intolerance for waste’
     ;streamlining and integrating health programmes ‘; and ‘channelling good aid ‘in ways that strengthen existing infrastructure and capacities.’5

    She also calls for ‘nothing less than a radical change in mindset, a fundamental rethinking of the way health systems deliver services and maintain good health outcomes.’6

    Reflecting on the last decade, Lord Crisp, who ran the UK National Health Service (NHS), from 2000-2006, and is also a Lancet Commissioner, acknowledges that while the reforms following the NHS Plan of 2000 ‘brought many improvements in services and service re-design,’ they ‘were too focused on economic incentives and hospital services.’ He further reminds us that ‘[a]s the NHS enters a new phase in the continuing development of GPs as commissioners and providers, there is a need to look for insights from around the world and to develop a new approach to educating and training primary care and public health professionals, which takes account of this global perspective and global learning’ and ‘in helping develop an NHS workforce for the future.’7, 8

    In summary, providing more compassionate and competent patient/social care in this decade and beyond necessitates structural changes in the way we prepare our health/social care professionals. It also requires broader and more ‘joined-up’ thinking and commitment -social, political, economic- on what needs to be done, by whom, how and by when – in terms of health and social care. Given the state of finances across many nations, deliberations along these lines cannot start soon enough.

    An important theme throughout the book is that, while health systems will have to change to meet health and social care expectations, so do we! - in order to embrace the transition to a healthier social and cultural environment.


    Author’s note: Reviews of the book from different corners of the world have been numerous and positive. An in-depth review by Peter Sharp, CEO of the UK Centre for Workforce Intelligence (CfWI), is available to read on The Lancet Commission website.9  Several others can be found on the publisher’s web link, which also provides a table of contents.10


    1Frenk J, Chen L, Bhutta ZA, Cohen J, et al. ‘Health Professionals for a New Century: transforming education to strengthen health systems in an interdependent world.’ The Lancet.

    2Duffy TP. The Flexner Report undefined 100 Years Later. Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858/ (accessed 8 October 2011).

    3Lueddeke GR. Transforming Medical Education for the 21st Century: megatrends, priorities and change. London UK: Radcliffe Publishing Ltd; 2012.

    4House of Commons (Health Select Committee). First Report-Education, Training and Workforce Planning. Available at:http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/6/602.htm (accessed 25 May 2012). 

    5Chan M. Best days for public health are ahead of us, says WHO Director General. Address to the Sixty-fifth World Health Assembly. Geneva, Switzerland: WHO; 21 May, 2012.

    6Chan M. WHO Director-General addresses conference on health systems. Keynote address at the International Conference on Oman Health Vision 2050: Quality Care, Sustained Health. Muscat, Oman. Geneva, Switzerland: WHO; 30 April 2012.

    7Crisp N. A Global Perspective on the Education and Training of Primary Care and Public Health Professionals. London Journal of Primary Care; November 2011.

    8Crisp N. Turning the World Upside Down – the search for global health in the 21st century. London: Royal Society of Medicine; 2010.

    9Sharp P. New Book on Transforming Medical Education Reviewed. Available at: http://healthprofessionals21.org/index.php?option=com_content&view=article&id=109:lueddeke-book-reviewed&catid=7:news&Itemid=136 (accessed on 14 July 2012).

    10Radcliffe Publishing. Transforming Medical Education for the 21st Centurymegatrends, priorities and change. Available at:http://www.radcliffehealth.com/shop/transforming-medical-education-21st-century-megatrends-priorities-and-change(accessed 12 February 2013).

    George R Lueddeke PhD

    George is keen to share and discuss findings from his research on the future of medical/healthcare education and, time permitting, welcomes invitations to present to either small or larger groups (email-glueddeke@aol.com)

    LinkedIn Connection: http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401

  • 19 Feb 2013 10:42 PM | Anonymous member

    George Lueddeke OCT MEd PhD

    Article Contributor

    George Lueddeke OCT MEd PhD is an educational consultant in higher and medical education.  He has held posts in educational and organisational development, management, research and teaching in both Canada and the UK and has led a number of provincial and national projects.  Specialising in higher and medical education, educational development and change management, he has also conducted workshops and seminars in Canada, the US, the UK and Sri Lanka as well as for visiting groups (e.g. from China, Mexico, Malaysia, Japan). Previously, he was senior lecturer in medical education at Southampton University’s Faculty of Medicine and consultant education adviser with the KSS (Kent, Surrey and Sussex) Postgraduate Deanery in London.

    He has presented at international conferences and seminars on change management, curriculum planning and historical perspectives on medical education.  Most recently, he conducted seminars on his current book, Transforming Medical Education for the 21st Century: Megatrends, Priorities and Change, at several medical schools and was invited to be a keynote speaker at the annual UK Centre for Workforce Intelligence conference (London and Leeds). He will also present at three other conferences in the coming months: at the ‘Leaders for European Public Health - Senior Public Health Policy Forum (Brussels, 21 March); Universitas 21, Health Sciences conference (Dublin, 3 September); and at an American Medical Association (AMA) conference (Chicago - late October /early November).

    George is keen to share findings from his research on the future of medical/healthcare education and welcomes invitations to present to either small or larger groups (email-glueddeke@aol.com)

    LinkedIn Connection:


  • 18 Feb 2013 11:27 PM | Anonymous member

    Save 15%

    'Transforming Medical Education for the 21st Century: Megatrends, Priorities and Change' by George R. Lueddeke

    The link to purchase this book from Radcliffe Books is: http://goo.gl/dTHpT

    Reviews of this book:

    UK Royal College of General Practitioners:


    The book certainly raises awareness about the growing importance of public and global health, primary health care and the need for greater collaboration among the developed and the developing worlds. 

    Here is a review of the book by Peter Sharp, CEO at the UK Centre for Workforce Intelligence (CfWI), that now appears on The Lancet Commission home page: 



    “Speaking for myself who has worked in various contexts – healthcare institutions, rural villages, government bureaucracies –with the goal of improving the health of people, this book allows me to look back at my experiences with new eyes and enables me to look at future challenges with imagination and new inspiration.” 

    Dr Manuel M Dayrit, Director, Department of Human Resources for Health, World Health Organisation (previously Minister of Health for The Philippines)


    "This book could be transformative and a turning point in medical education specifically and healthcare education generally. It is a step in the right direction and should be required reading for educators, students/trainees and managers in medicine, nursing, public health and other health/social care professions. It is a driver and facilitator in advancing progress in interprofessional education."

    Professor Afaf I. Meleis, Margaret Bond Simon Dean of Nursing, University of Pennsylvania, United States 


    "Undoubtedly, the book will challenge many to rethink healthcare, health systems and health/medical education in a global context that is changing with unprecedented speed and scope."

    Dr Catherine Michaud, Consultant, The China Medical Board, Boston, Massachusetts, United States


    "Global developments set the scene for the radical changes in the education and training of health professionals. Ultimately, it is transformation in how health professionals work, and most fundamental of all, in how they think and how they understand the world that will lead to improvements in health and healthcare."

    Lord Nigel Crisp, House of Lords, London, United Kingdom 


    " I LOVE IT. This book is amazing and your input is excellent, brilliant and smashing - it is lived and real leadership !!!! Congratulations."

    Professor Dr. med. Björn Brücher, Professor of Surgery, Medical Director Peritoneal Surface Malignancies Center of Excellence & Chief, Division of Cancer Research, BSNCI Bon Secours National Cancer Institute, United States; Founder of the Theodor-Billroth-Academy® University of Tübingen, Germany


    "This book will be of interest to all because it offers more than just a discussion of changes in the education of health professionals; it offers suggestions to real enabling actions."

    Professor Patricia J Garcia, Dean, School of Public Health and Administration, Universidad Peruna Cayetano Heredia, Lima, Peru


    "I've read your book, thoroughly enjoyed it, and have now shared it with others. Thanks for this terrific synthesis and contribution to the field.

    Dr Joseph Kolars, M.D. Senior Associate Dean for Education and Global Initiatives at the University of Michigan Medical School. http://www.med.umich.edu/medschool/dean/deans/kolars.htm


    "I continue to use your book which is excellent....and seminars here would be a good idea."

    Professor Geoff McColl, Consultant Rheumatologist, deputy dean of Medicine, Dentistry and Health Sciences, and director of Melbourne University's Medical Education Unit, Melbourne, Australia


    "I like your book...lots of innovative thinking" (to be translated into Polish) "... recommended to members of the European Public Health Future Research Working Group (Director General Research of the European Commission)

    Dr Miroslaw J. Wysocki, Director General, National institute of Public Health - NIH, Warsaw, Poland


    "I have gone through your book and find it very informative as it provides a comprehensive analysis of health/social care issues facing the developed and developing worlds and highlights the need for strengthening medical/healthcare education and training - coping with emerging needs and global developments. I am optimistic that this manuscript will pioneer a new thought process and will be useful in scaling up human resources for health and increasing their productivity in line with the Global Health Workforce Alliance strategy for 2013-2016: 'advancing the health workforce agenda within universal coverage."

    Dr Muhammad Mahmood Afzal, Head of Country Facilitation Team, Global Health Workforce Alliance (GHWA), Geneva, Switzerland


    "I have indeed read your new book and recommended it to a number of AMA colleagues. It is an excellent summary of the state of medical/health care education today and issues for the future....I am a fan of your work and it has influenced my thinking as we put this program together.

    (The AMA 'have just announced an RFP for $10M to fund 8-10 schools for bold, innovative projects'. (www.changemeded.org)

    Susan E. Skochelak MD, MPH

    Vice President, Medical Education

  • 18 Feb 2013 9:38 PM | Anonymous member

       Top tips for avoiding fines

       from HSE’s new Fee for

       Intervention Scheme

    Top tips for avoiding fines from HSE’s new Fee for Intervention Scheme


    As of the 1st October 2012 the Health & Safety Executive (HSE) introduced a new scheme which is catching companies out left right and centre however by following a few simple steps your company can avoid becoming part of the growing statistics.

    What is it and how does it affect you?

    Health and Safety training is a legal obligation if a company employs more than 5 people, no matter what tasks and duties are undertaken. Even if your role is entirely office based and you sit at a computer answering a telephone all day long you still have to be provided with appropriate training for your role.   Each company throughout the UK could be subject to an HSE inspection at any time and the new ‘Fee for Intervention’ scheme is aimed at those who fall just shy of the required laws.

    The scheme is being termed as a "Cost Recovery Scheme" and as such allows the HSE (www.hse.co.uk)  to charge an hourly fee to put right any items which cause concern during an inspection or investigation.  There is no consultation period and the corrections are implemented immediately thus meaning the fee is also payable immediately.

    The fee is currently set at £124 per hour and this can soon cost your company thousands once you look at travel, re-inspection, minor misdemeanours and other expenses which you may not consider...remember £124 is an hourly rate not a maximum fee.   

    Legally what should you be trained in?

    Training is essential to comply with the law and responsibilities as an employer.  Those laws state that you must provide appropriate training to all of your employees regardless of their job role.

    Training can be undertaken in a number of different forms and reinforced regularly.  Courses can be provided through DVDs, classroom presentations, e-Learning or a one to one chat with your designated officer and reinforced through posters around the workplace and aid memoires like booklets.  Courses such as DSE, Fire Safety and Manual Handling are relevant to nearly every employee in every work situation but additional training such as COSHH, Moving & Handling People and Driving Safely may also be appropriate.  

    How can you minimise the risk of being fined?

    As with most things in life prevention is better than the cure and Safety Media has a range of over 50 courses across a variety of platforms to meet every need you may have in the workplace.    

    Traditionally Safety Media has provided training in the form of DVDs, Posters, Assessment Forms and Booklets and of course we still provide these solutions as part of our library.  The main focus however, not only in Safety Media but also across the board in the world of training, is e-Learning and technology focused solutions.  This new approach to training allows you to provide competency and compliance evidence which more traditional methods may lack.  There is full record keeping and a comprehensive audit trail available on each of the Safety Media e-Learning solutions.  As an administrator you would have complete access to over 50 training titles which can be allocated on a needs basis to your staff as you see fit.  All of our courses are CPD certified and the majority are RoSPA accredited with more on the way. You will receive emails to tell you who has completed their training as well as who is overdue and each course comes with a fully editable risk checklist so you can take any required measures deemed necessary to minimise risks in your workplace.

    What next?

    If you would like to set up a trial account so you can take a look around the system and courses either guided by one of our consultants or in your own time you can just give us a call on 0845 345 1703 and we will get you set up in minutes.    Quote CPDme when you call and benefit from taking a look at our specialist courses too.  

    For more information visit www.safetymedia.co.uk or email us at sales@safetymedia.co.uk


    Established in 1995, Safety Media Limited is a World Class provider of Health & Safety training solutions including courses on Fire Safety, Computer Safety, Risk Assessment, Induction Safety, Stress, and Driving Safely.   With revolutionary E-Learning packages to suit all budgets and Safety Media's buy 2 get 1 free deal on each range of DVDs we are confident that you can meet your health & safety requirements in the most cost effective way possible all under one roof.

    Safety Media’s E-Learning system and courses has been a finalist in the 2009 and 2012 E-Learning Awards.  The system features over 50 flash interactive and video based Health & Safety training courses in an ever evolving library of titles.  There are currently over 450 companies using E-Learning from Safety Media ranging from blue chip organisations, to universities and colleges.

    Further information from:

    Phone: 0845 345 1703

    Fax: 01745 536195

    Email: sales@safetymedia.co.uk

    Website: www.safetymedia.co.uk 

    For all media enquiries please contact Claire Williams at:

    Safety Media Ltd

    5a Kinmel Park

    Abergele Road



    LL18 5TX

    E: claire.williams@safetymedia.co.uk

    T: 01745 536470

    For further information about Safety Media: www.safetymedia.co.uk

    For high resolution images, please email elin.williams@safetymedia.co.uk

    Company No. 3124807 Registered in Wales

  • 15 Feb 2013 8:54 AM | Anonymous member (Administrator)
    CPDme Members get 25% off the Pre-Hospital Trauma Symposium

    CPDme are pleased to announce that our Members are entitled to 25% discount off the 2013 Pre-Hospital Trauma Symposium offered by Mountain Trauma.

    Simply quote your membership number when ordering your place.

    See the full line up of events and workshops and ordera place today by visiting:

    Not a member of CPDme? No Problem, use discount code "TRAUMA2013" and get 25% off our membership packages too. click here and get your membership today.

    Limited offer so hurry up before the offer ends on the 21st Feb 2013.
  • 12 Feb 2013 12:37 AM | Anonymous member

    Ambulance Services Benevolent Fund Champions


    Do something amazing for 2013!

    Please support the only country wide ambulance services charity.

    If you would like to join our growing team of ASBF Champions, raise funds or volunteer your time to help us in any way, please get in touch.

    Visit our website:


    Or email the Secretary:


     ‘The Ambulance Services Benevolent Fund is Caring for the Carers but together we will make the difference!’

    Patron: Simon Weston OBE.

    Registered charity # 800434 

  • 11 Feb 2013 10:19 PM | Anonymous member

      Sarah Dawkins

      Article Contributor

    I qualified in 2001 and have worked predominantly within the Cardio-Thoracic specialty both on the Wards and in Recovery, in the UK and the USA.  I have, to date, published three articles, with a fourth in the wings, as well as presented my PACU/Nurse led extubation work three times in different venues.  I am always looking for ways to enhance patient care and am an advocate to patients too.

    My MSc is almost complete and I have also undertaken a teaching certificate. I love to learn and share knowledge and imparting it is helping me to grow and learn as well as others.

    Contact details:

    Website:   www.sarahdawkinshealthconsultancy.com

    LinkedIn:  uk.linkedin.com/in/sarahdawkins/  

  • 11 Feb 2013 9:05 PM | Anonymous member

    Background, Responsibility and Implications for PACU Practitioner and Nurse led extubation


    Sarah Dawkins

    Background, Responsibility and Implications for PACU Practitioner and Nurse led extubation 


    A review of current literature highlighted the lack of national or local guidelines for Post Anaesthetic Care Unit (PACU) Practitioners/Recovery Room Nurses to extubate their own patients.  Extubation is described as the discontinuation of an artificial airway.  An artificial airway can be described as a plastic or rubber device that can be inserted into the upper or lower respiratory tract to facilitate ventilation or the removal of secretions (Farlex Inc 2011).

    Reviewing the Code of Professional Conduct (Nursing and Midwifery Council (NMC 2008)  and the Health Professional Council (HPC 2008) raised concern about practice with regards to extubating post-operative patients.  The NMC and HPC both state that as professionals, we are personally accountable for actions and omissions within our practice, must always be able to justify our decisions, act lawfully, deliver care based on best available evidence, act as an advocate and treat people with dignity.  Failure to comply with the code may bring fitness to practise into question and endanger registration.  

    Literature Review

    A systematic literature review of patient extubation by PACU Nurses was undertaken.  Systematic literature reviews optimise practice from the evidence of effectiveness and efficiency within the field of Health Care (Black et al 2000) and Gray (2001) suggests that a critically assessed, high quality literature review forms the basis of evidence based clinical practice.  

    As suggested by Aveyard (2007) and Cronin et al (2008), the first stage in conducting a literature review is to identify an appropriate topic.  The topic for this literature review was “PACU Practitioner/ Nurse led patient extubation for Endotracheal tubes (ETT’s)”.  Electronic literature only was reviewed due to timescales. .  Electronic searching is quick and convenient, allowing for articles to be sourced more rapidly than alternative methods (Page 2008). 

    The literature review was undertaken with a view to producing an evidence based, best practice guideline booklet for PACU Practitioners (Nurses, Nursing students, Operating Department Practitioners (ODP), ODP students and trainee Doctors) working within the PACU area, that are involved in patient extubation with EndoTracheal Tubes (ETT).   The Association of Anaesthetists of Great Britain and Ireland guidelines (AAGBI 2002) and the American Association for Respiratory Care (AARC 2007) for general ETT extubation were also read for pertinent information.  

    The Department of Health (DoH 2001) published A Framework for Lifelong Learning in the NHS.  It states that as Nurses, we need to be able to reflect, evaluate and modify our practice, ensuring that we are up to date and with current research and legislation. Gray (2009) suggests that a critically assessed, high quality literature review forms the basis of evidence based clinical practice.  

    The first review of the literature highlighted a lack of national guidelines and standards for Nurses/Perioperative Practitioner to undertake ETT extubation, however The Association of Anaesthetists of Great Britain and Ireland (2002) stated that an appropriately trained Nurse may remove a Laryngeal Mask Airway (LMA) but that an Anaesthetist must remove an Endotracheal Tube.  


    The Anaesthetist that administers the anaesthetic remains responsible for the removal of the ETT from the patient, whether that is within the Theatre or PACU setting (AAGBI 2002).  The Association for Perioperative Practitioners (AfPP 2007) recommend that if the responsibility is delegated to a PACU Practitioner, that the practitioner should have received validated training and be deemed competent to perform the task.  As no national, validated training package is available for PACU Practitioners, a local training package to develop and validate knowledge and skills around airway management was developed by myself following a systematic literature review and discussions with local Consultant Anaesthetists. 

    Delegation is a two way process.  If an Anaesthetist delegates an intubated patient to the care of a PACU Practitioner and they accept that delegation, that practitioner must have the knowledge and skills to be aware of the consequences of the delegation.  Their performance in this skill will be judged against the performance expected by Anaesthetists. The person to whom the task is delegated has a duty to inform the Anaesthetist delegating the task if the task is outside their area of competence (Burnard, Morrison 1994).

    The AAGBI guidelines (2002) further state that when care or treatment is delegated, the Anaesthetist must be satisfied that the person to whom they delegate has the qualifications, experience, knowledge and skills to provide the care or treatment involved and that the Anaesthetist must always pass on enough information about the patient and the treatment they need, as they will still be responsible for the overall management of the patient.


    According to Rassam et al (2005) and Karmarker and Varshney (2008), airway related complications at extubation, are more common than problems at intubation, many aspects of which are controversial with no clear guidelines, giving cause for concern for patient safety and training.  Reviewing the numerous complications that can arise in the immediate post extubation period reinforces the responsibility for the individual undertaking the extubation and is a critical time for vigilant nursing assessment and care (Ead 2004).  Airway complications include; laryngospasm, laryngeal oedema, bronchospasm, aspiration and pulmonary oedema as well as anatomical changes, including short neck, sleep apnoea, cleft palate, small chin and obesity.

    The New NHS (DoH 1997) made it clear that practitioners must accept responsibility for developing and maintaining standards within their local NHS organisations.  The AAGBI (2002) state that practical training and maintenance of skills must supplement theoretical knowledge and training should be tailored to meet the needs of the individual and recovery room.  Providing suitably trained practitioners would cover the Clinical Governance aspects specific to education, training and continuous professional development.  

    Cardiac Patients

    By broadening the literature review search to include cardiac surgery some articles around Nurse led, fast track extubation of cardiac patients were found with documented protocols to perform patient extubation within ICU settings. The criteria for extubating cardiac patients is comprehensive and involves blood loss, blood pressure, heart rate and rhythm, arterial blood gases, sedation breaks, ventilator weaning procedures, respiration rates, neurological assessment and medication.  Once all those criteria are satisfactory, the protocol dictates how the patient should be extubated ie, with the trailing suction catheter.  If Nurses were able to follow an agreed protocol to be able to extubate patients in the ICU setting, could those skills be transferrable to the PACU setting?  

    The PACU Practitioner

    It was deemed that in order to undertake patient extubation, knowledge of the patient’s anatomy and physiology was needed.  This includes airway anatomy, inspired oxygen concentration, pulse oximetry, tidal volume, hypoxia and expired carbon dioxide as well as heart anatomy and physiology, heart rate and blood pressure.  The PACU Practitioner also needs to understand how to maintain a clear airway as well as how to manage an airway obstruction ie. undertaking an effective head tilt, chin lift,  jaw thrust, inserting appropriate nasal and/or oral airways and the use of suction.  Knowledge of pharmacology related to anaesthesia and analgesia is required to enable the PACU Practitioner to safely extubate a patient.  For example, recurarisation is a phenomenon of recurrence of neuromuscular block and it may occur where the reversal agents wear off before a neuromuscular blocking drug is completely cleared (Schultheis 1989).  This is important to understand as it has implications for airway management.  The PACU Practitioner also needs to understand the differences and implications of Total IntraVenous Anaesthesia (TIVA), which can cause apnoea and hypotension and gaseous anaesthetics which increase nausea and vomiting, in order to manage the extubation process.

    When preparing to extubate a patient, clinical considerations for the possible management of post extubation hypoventilation, airway compromise and obstruction should be taken into account.  Clinical practice standards for endotracheal tube removal include attentive post extubation monitoring, prompt identification of respiratory distress, maintenance of a patent airway and, if clinically indicated, attempts to successfully establish an artificial airway by reintubation or in rare situations, surgical technique (AARC 2007).

    Airway obstruction in the conscious patient is easily recognised as it leads to strenuous efforts on the part of the patient to overcome it.  However, airway obstruction in the unconscious patient may not exhibit classical compensatory signs. Paradoxical chest movement, where the upper abdomen and chest see-saw (the chest retracting and the abdomen sticking out) during attempted inspiration can be seen.  Air movement cannot be detected by listening at the mouth due to the lack of air entry and exit.  The patient will eventually become cyanosed if left untreated.

    Conclusion and limitations of the Literature Review

    The literature review has a number of severe limitations. The most valid and high quality literature reviews are normally conducted by a team of experienced researchers who have access to a wide range of skills, experience and knowledge.  This review could have been significantly strengthened if it was conducted with the support of a team to duplicate the literature search and validate the application of inclusion criteria and critical appraisal in order to minimise the risk of bias.  In addition, the sources of literature were focused entirely on electronic sources and therefore many other potential sources of relevant literature were not considered.

    Changes to Practice

    Following the systematic literature review, Consultant Anaesthetists were liaised with and the information gained with regards to extubation, was utilised.  A PACU Practitioners guide to extubation was subsequently written. This literature review informs the written guidelines in respect of Privacy and Dignity, Administration of Medicines, Safety in the Environment and Safeguarding Vulnerable Adults in relation to the DoH’s Essence of Care (DoH 2010).  A comprehensive flow chart with the essential information with regards to patient extubation with ETT’s as a quick reference guide for the Nurses to refer to, was then developed from the information realised from the literature review.

    Once the PACU Practitioner guidelines were written, the Airway Management training, including knowledge, skills and competency assessment was developed after liaising with the Anaesthetists. These are in relation to the ability to maintain a patent airway, ventilate a patient, use of artificial airways (oral/nasal/i-gel LMA) and through discussion around causes and management of airway obstructions.

    Whilst there remains a lack of national guidance for PACU Practitioners to extubate patients, the local guidance now written will standardise practice and give guidance on dealing with the problems that they face on a daily basis.

    The actual PACU Practitioner/Nurse led extubation guidelines handbook, algorithm and competencies can be purchased from   



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    About the author

    Sarah Dawkins

    I qualified in 2001 and have worked predominantly within the Cardio-Thoracic specialty both on the Wards and in Recovery, in the UK and the USA.  I have, to date, published three articles, with a fourth in the wings, as well as presented my PACU/Nurse led extubation work three times in different venues.  I am always looking for ways to enhance patient care and am an advocate to patients too.

    My MSc is almost complete and I have also undertaken a teaching certificate. I love to learn and share knowledge and imparting it is helping me to grow and learn as well as others.

    Contact details:

    Website:   www.sarahdawkinshealthconsultancy.com

    LinkedIn:  uk.linkedin.com/in/sarahdawkins/

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