Royal College Of Anaesthetists Research Articles

Cost of Training Crisis: Anaesthetics.

The anaesthetic training programme in the United Kingdom (UK) spans over seven years and is overseen by the Royal College of Anaesthetists (RCOA). Junior doctors in England are currently striking amid ongoing pay negotiations with the government, and almost all junior doctors are worried about the cost of living. This article provides an overview of the average financial cost of training for doctors in the anaesthetic training programme. The cost incurred by anaesthetic trainees illustrates the level of financial burden faced by trainees across multiple specialities. The cost includes: student loan repayment (with interest rates), compulsory membership fees (including the Royal College of Anaesthetists and General Medical Council), postgraduate examinations (Fellowship of the Royal College of Anaesthetist exams are compulsory to complete training) and medical indemnity. The average trainee spends between 5.6% and 7.4% of their annual salary on non-reimbursable costs. This article delineates for aforementioned expenses and compares them with the training programs in Australia and New Zealand, given their status as frequent emigration destinations for UK doctors.

Emergency treatment of peri-operative anaphylaxis: Resuscitation Council UK algorithm for anaesthetists.

Peri-operative anaphylaxis is a rare but potentially catastrophic event which must be considered whenever unexpected and significant cardiovascular or respiratory compromise occurs during anaesthesia. The Resuscitation Council UK algorithm for peri-operative anaphylaxis highlights the importance of early intravenous adrenaline and fluid resuscitation and provides guidance on the treatment of refractory anaphylaxis and immediate follow-up. This algorithm is endorsed by the Royal College of Anaesthetists, Association of Anaesthetists, British Society of Allergy and Clinical Immunology and Clinical Immunology Professional Network of the British Society for Immunology. This document was produced by the Perioperative Allergy Network steering committee in collaboration with the Resuscitation Council UK.

Regional anaesthesia training in the UK – a national survey

BackgroundAdequate training of anaesthetists in regional anaesthesia is important to ensure optimal patient access to regional anaesthesia. MethodsWe undertook a national survey of UK trainee anaesthetists and Royal College of Anaesthetists (RCoA) tutors to assess experiences of training in regional anaesthesia. We performed descriptive statistics for baseline characteristics, and logistic regression of training indices and tutor confidence that their hospital could provide regional anaesthesia training at all three stages of the RCoA 2021 curriculum. ResultsA total of 492 trainees (19.2%) and 114 tutors (45.2%) completed the survey. Trainees were less likely to have received training in chest/abdominal wall compared with upper/lower limb blocks {erector spinae vs femoral block (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.16–0.39), P<0.001}, or achieved >20 chest/abdominal wall blocks by Stage 3 of training (chest vs lower limb block [OR 0.09, 95% CI 0.05–0.15, P<0.001]. There was a strong association between training received, number of blocks performed (>20 vs 0–5 blocks), and self-reported ability to perform blocks independently, OR 20.9 (95% CI 9.38–53.2). 24/182 (13%) and 10/182 (5.5%) of trainees had performed ≥50 non-obstetric lumbar and thoracic epidurals, respectively, by Stage 3 training. There was a positive association between having a lead clinician for regional anaesthesia, particularly those with paid sessions, and reported confidence to provide regional anaesthesia training at all stages of the curriculum (Stage 3 OR 7.27 [95% CI 2.64–22.0]). ConclusionOur results confirm the importance of clinical experience and access to training in regional anaesthesia, and support the introduction of departmental regional anaesthesia leads to improve equity and quality in training opportunities.

1149 Bringing Recycling to the Operating Department - a Sustainability Project in a DGH in London

Abstract Aim The Lancet Commissions report of 2015 suggested that tackling climate change could be the greatest global health opportunity of the 21st century. Both the Royal College of Surgeons of England and the Royal College of Anaesthetists have committed to sustainability task forces and have published guidance on improving care through small, sustainable practices including recycling waste. Method We conducted a theatre staff survey on SurveyMonkey in an operating department in an acute district general hospital without any recycling facilities on the attitudes towards recycling, and how this could be implemented. Results We received 103 responses, including a broad spectrum of the multi-disciplinary team including surgeons, anaesthetists, scrub nurses, operating department practitioners and healthcare assistants. Results showed that little to no recycling occurred (59%), 48% of respondents were not familiar with which material can be recycled, and 96% were agreeable to improving access to recycling in theatres. Two main areas identified as barriers to recycling were inadequate access to recycling bins and inadequate information on what can and what cannot be recycled. In terms of implementation, 75% of respondents indicated that posters around the department would be most useful in raising awareness and providing information on recyclable materials. Conclusions Currently, we are in conversation with the Trust and the waste management company to identify a list of recyclable materials and to incorporate recycling bins as part of the waste management pathway.

Improving handover in recovery

Background: An anaesthetist’s responsibility for patient safety continues into the recovery area where the patient remains at risk of surgical and anaesthetic complications. The multidisciplinary team is of vital importance, with recovery nurses taking a leading role in patient care. A clear handover between professionals should ensure continuity, quality, and safety of patient care.1 The Royal College of Anaesthetists provides guidance about this handover.2 Studies have shown that the use of checklists in anaesthesia can decrease human error, and improve teamwork and quality of care.3 In this project, we aimed to evaluate the quality of handovers in the recovery area at Inverclyde Royal Hospital and identify how these may be improved. Methods: An online questionnaire was sent to all theatre staff via Microsoft Forms with questions about the quality of the current handover process. Using this information, a ‘Recovery handover checklist’ was created and presented at the anaesthetic departmental meeting. We then trialled using a distraction-free ‘pause’ and the checklist, displayed in every recovery bay, to structure handovers over a 4-month period. A second online questionnaire was sent to all theatre staff with questions about the impact of this change. The length of handover was timed before and after the change. Results: The initial questionnaire received 20 respondents, including recovery nurses, anaesthetists, anaesthetic nurses, and theatre nurses. Some 65% of respondents thought current handover was not adequate. Fifty-five percent thought not all relevant information was handed over. Eighty-five percent thought there were distractions during handover. The follow-up questionnaire received 38 respondents, again from the full multidisciplinary team. Some 71% of respondents thought the ‘pause’ for handover had been useful and 76% would be keen to continue this. Eighty-two percent thought that there were fewer distractions during handover. However, 73% of recovery nurses thought that staff are only sometimes pausing before handover. There was no increase in average time taken for handover after the changes. Conclusion: Most of the multidisciplinary team at our hospital have found the introduction of a distraction-free ‘pause’ and checklist for handover in recovery useful. This new handover process has not increased the length of time taken for handover. Further work should include promotion of the checklist so that it is used more consistently in our department. 1.Arora V, Johnson J. Jt Comm J Qual Patient Saf 2006; 32: 646–552.Royal College of Anaesthetists. Novice Guide 2019. https://www.rcoa.ac.uk/documents/novice-guide/typical-day-novice (accessed 20/03/23)3.Saxena S, Krombach JW, Nahrwold DA, Pirracchio R. Anaesth Crit Care Pain Med 2020; 39: 65–73

Ask an anaesthetist: informing parents about pain relief options in labour

Background: Approximately 60% of women require anaesthetic intervention around the time of delivery of their baby.1 The National Institute for Health and Clinical Excellence and the Royal College of Anaesthetists both recommend that women should have access to information about analgesia and anaesthesia during labour.2 3 Often, the first time a mother meets an anaesthetist is during labour, when taking on new information and making informed decisions can be overwhelming. We aimed to elicit if there is a desire for further antenatal advice about analgesic options during labour, and if so, design a meeting to achieve this. Methods: We conducted a survey of postnatal mothers who had anaesthetic intervention during labour. Questions aimed to identify where they had received information about pain relief antenatally and whether they wished they had known more about the analgesic options available. The survey could be completed in 2 min and a QR code to link to the survey was provided to mothers during routine postnatal anaesthetic review. Results: The survey received 49 responses; 67% of respondents were primiparous. Midwives (n=36) were the commonest source of antenatal information regarding pain relief in labour, while anaesthetists were the source in just two cases. Some 22% of respondents agreed that they wished they had known more about pain relief options in labour, whereas 39% wanted to know more about the different types of anaesthetic that they might need. Some 49% of respondents were in favour of attending a group meeting antenatally to discuss pain relief during labour, with 63% being in favour of an online meeting. Based on the survey responses, we set up ‘Ask an Anaesthetist’—a service designed to enable parents to learn about the analgesic options in labour. The online session covered non-pharmacological, pharmacological, and regional options, and a question-and-answer feature was included. The sessions were advertised and delivered in collaboration with Health Matters, our Trust’s programme for public information and engagement, and the Maternity Voices Partnership, an NHS working group that works to develop local maternity care. Feedback was gained to enable improvement of future sessions. Conclusion: There is an appetite for further specialist advice antenatally about analgesic options during labour. An online session delivered by anaesthetists enables information to be given to expectant parents in an evidence-based and non-biased fashion. Collaboration with the Health Matters team and the local Maternity Voices Partnership group has enabled adequate reach to the target audience and ensures expectant mothers’ voices are heard. We plan to continue the delivery of these sessions to parents in the local area four times a year, developing the session as necessary based on feedback received. 1.NHS Digital. NHS Maternity Statistics – England 2021-22.National Institute for Health and Clinical Excellence. Antenatal Care. Clinical Guideline NG201, 20213.Royal College of Anaesthetists. Guidelines for the Provision of Anaesthetic Services. Chapter 9: Guidelines for the Provision of Anaesthetic Services for an Obstetric Population, 2023

Operating theatre efficiency at a tertiary eye hospital in South Africa

South Africa (SA) is a resource-limited country that needs efficient operating theatres in order for surgical care to function cost-effectively. Regular assessment of theatre efficiency in our setting is therefore needed. To describe ophthalmology theatre efficiency at a central hospital in SA and compare this with international benchmarks. St John Eye Hospital is the ophthalmology section of Chris Hani Baragwanath Academic Hospital in Soweto, SA. It has three operating theatres. A cross-sectional study was done of the theatres' registry of surgical procedures over a 6-month period. Data analysed included the starting and finishing times of theatre lists, surgical cases that were cancelled on the day of surgery, and theatre utilisation rates. These data were compared with international benchmarks. A total of 1 482 surgical procedures in 229 theatre lists were included in the study. Sixty-five percent of these theatre lists started late, accounting for 4 236 minutes of lost theatre time, significantly more than the maximum of 10% recommended by the Royal College of Anaesthetists. Of theatre lists, 23% and 30% finished after 16h15 (theatre overrun) and before 16h00 (theatre underrun), respectively. This is more than double the 10% recommended by the Royal College of Anaesthetists. The theatre utilisation rate was 62%, which is significantly lower than the ideal utilisation rate of 80%. The cancellation rate was 16%, which is significantly higher than the international benchmark of 2% recommended by the New South Wales guidelines. The most common reasons for cancellations were medical unfitness of the patient and lack of operating theatre time. All theatre efficiency parameters at St John Eye Hospital were below international benchmarks.

Patient characteristics, anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey.

Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3-4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapshot activity survey in all UK hospitals delivering anaesthesia, collecting patient-level encounter data from all cases under the care of an anaesthetist. During November 2021, as part of NAP7, anaesthetists recorded details of all cases undertaken over 4 days at their site through an online survey capturing anonymous patient characteristics and anaesthetic details. Of 416 hospital sites invited to participate, 352 (85%) completed the activity survey. From these, 24,177 reports were returned, of which 24,172 (99%) were included in the final dataset. The work patterns by day of the week, time of day and surgical specialty were similar to previous NAP activity surveys. However, in non-obstetric patients, between NAP5 (2013) and NAP7 (2021) activity surveys, the estimated median age of patients increased by 2.3 years from median (IQR) of 50.5 (28.4-69.1) to 52.8 (32.1-69.2) years. The median (IQR) BMI increased from 24.9 (21.5-29.5) to 26.7 (22.3-31.7) kg.m-2 . The proportion of patients who scored as ASA physical status 1 decreased from 37% in NAP5 to 24% in NAP7. The use of total intravenous anaesthesia increased from 8% of general anaesthesia cases to 26% between NAP5 and NAP7. Some changes may reflect the impact of the COVID-19 pandemic on the anaesthetic population, though patients with confirmed COVID-19 accounted for only 149 (1%) cases. These data show a rising burden of age, obesity and comorbidity in patients requiring anaesthesia care, likely to impact UK peri-operative services significantly.

Management of transgender patients in critical care.

As clinicians working in critical care, it is our duty to provide all of our patients with the high-quality care they deserve, regardless of their gender identity. The transgender community continues to suffer discrimination from the media, politicians and general public. As healthcare workers we often pride ourselves on our ability to safely care for all patients. However, there remains a distinct lack of understanding surrounding the care of critically ill transgender patients. This is likely in part because the specific care of transgender patients is not included in the Faculty of Intensive Care Medicine's, Royal College of Anaesthetists', Royal College of Physician's, or Royal College of Emergency Medicine's curriculum. There are several important considerations relevant for transgender patients in critical care including anatomical changes to the airway, alterations to respiratory and cardiovascular physiology and management of hormone therapy. Alongside this, there are simple but important social factors that exist, such as the use of patient pronouns and ensuring admittance to correctly gendered wards. In this review we will address the key points relevant to the care of transgender patients in critical care and provide suggestions on how education on the subject may be improved.

Utility of the National Emergency Laparotomy Audit prognostic model in predicting outcomes in an Australian health system.

The Royal College of Anaesthetists was commissioned by the United Kingdom Health Quality Partnership to conduct the National Emergency Laparotomy Audit of England and Wales (NELA), to compare outcomes of patients undergoing emergency laparotomy in order to promote quality improvement. Prior to 2016 there were minimal data for emergency laparotomy patients in Australia. The aim of this cohort study was to assess the utility and applicability of the NELA model in a tertiary centre in Western Australia. NELA-related data of patients who underwent emergency laparotomy, between June 2018 and May 2020, were merged with other administrative databases and clinical records. The discriminative ability and calibration of the model were assessed by the area under the receiver operating characteristic (AUROC) curve and calibration plot, respectively. Cox proportional hazards regression was used to assess whether the NELA-predicted risks were an independent predictor of hospital mortality. Of the 502 patients included, 168 (33.5%) patients had a NELA-predicted risk >10%, and of these, 93 (55.4%) were admitted to a critical care unit in a planned fashion immediately after surgery. The NELA model had a good ability to discriminate between survivors and non-survivors (AUROC 0.892, 95% confidence intervals 0.854 to 0.93, P <0.001). However, the model was not perfectly calibrated, with the predicted risks tending to overestimate the observed risks of mortality, especially when the predicted risks were >50%. A high NELA-predicted risk remained significantly associated with mortality after adjusting for other covariates, including sepsis and plasma lactate concentration, suggesting that it is a reliable screening tool for identifying high-risk patients requiring emergency laparotomy.

Evaluation of automated manufacture of ready-to-administer injections to improve medicines safety in emergency intubation

Abstract Introduction Within the clinical setting of emergency anaesthesia the lack of ready to administer preparations poses a high risk to patients. The CIVAS@IP5 Medicines hub were approached by Cardiff and Vale University Health Board in response to a quality improvement project to prepare ready to administer anaesthesia. To manufacture these medicines required the use of semi-automated technology and development of manufacturing techniques to meet the quantity and range of products required including Ketamine, Rocuronium and Fentanyl. These are some of the first products developed for manufacture using a Grifill 4.0 Semi-automated Medicines Pump within the UK. Aim To develop new ready-to-administer products or use in emergency intubation scenarios within critical clinical settings, manufactured using innovative and newly developed processes. The products would be presented with the Royal College of Anaesthetists label colour scheme and have extended shelf lives assigned to allow suitability of use. Methods The project required three separate stages of methodology. First within Cardiff and Vale UHB, a clinical agreement on standardised concentrations of Ketamine, Fentanyl and Rocuronium was required. Secondly, development within CIVAS@IP5 of a Semi-automated compounding process that had been fully process mapped, assessed via HAACP analysis. This process was then validated for microbiological integrity and efficiency using Gage R&amp;R principles to prove repeatability and reproducibility of a quality product. The final stage involved collaborative development of the final presentation and facilitation of its use locally. Ethical approval was not required for this service development initiative and evaluation. Results The new methodology for semi-automated preparation of ready-to-administer injectable medicines gave the following capacity timings for the three agreed concentrations recommended by the Royal College of Anaesthetists. Fentanyl 250mcg in 5mL – 54 seconds per syringe (Batch size 200 syringes). Rocuronium 250mg in 10mL – 2 minutes per syringe (Batch size 50 syringes). Ketamine 100mg in 10mL – 1 minute 32 seconds per syringe (Batch size 40 syringes). These timings are compared to current documented preparations of 5 minutes 42 seconds for syringes made manually in pharmacy technical services settings. This meant Cardiff and Value UHB could be provided with their emergency intubation medication in a ready-to-use format within a pharmacy manufacturing capacity expenditure of 4 hours and 12 minutes per month when compared to the same manual preparation taking 26 hours. A literature search allowed extended shelf lives of up to 100 days to be applied to the products, and the labels designed in collaboration with anaesthetic colleagues in Cardiff and Vale UHB. The clinical impact is that for emergency intubation scenarios clinicians have ready-to-administer medications at the point of care. Discussion/Conclusion Use of semi-automation within Pharmacy Technical Services can greatly increase the production output of medicines allowing products where there is a current unmet demand to be prepared. The impact is an increased service capacity for the provision of well designed, clinically significant products to clinical areas improving efficiency, patient safety and clinical delivery of treatment in emergency situations.

Bridging the realism gap: using ‘low-fidelity’ simulation for high quality training

The Royal College of Anaesthetists recommends use of simulation-based-education (SBE) during the initial 12-week novice placement for new anaesthetic trainees [1]. For many UK anaesthetic departments, the complexity and cost of patient simulators [2] may reduce opportunities for SBE during novice training. However, avoiding the physical fidelity trap [3] and utilising both conceptual and psychological fidelity to good effect might mitigate this issue. As novice trainees are already familiar with the theatre environment from day-to-day clinical practice, the learning outcomes from SBE generally cover rarer emergencies which can still be covered during SBE outside of the theatre environment. We aimed to assess the feasibility of running weekly low physical fidelity SBE across the entire 12-week novice period instead of the smaller number of ad-hoc sessions delivered previously. Our new SBE programme consisted of 30-minute sessions held in the anaesthetic department conference room to minimise impact on stretched theatre capacity and educator availability. To further maximise efficiency, we created a portable simulation set-up using a basic resuscitation manikin on a patient trolley, a disused anaesthetic machine, and a tablet device with a simulated monitor application. This could all be set-up and stored away in under 5 minutes. Our focus on conceptual and psychological fidelity led to the creation of a new scenario bank which identified common issues encountered by new anaesthetic trainees, rather than emergencies rarely encountered by even an experienced anaesthetist. Scenarios needed to be highly plausible and solvable by the novice trainee. Learners were then asked to complete a feedback survey after each session. Feedback from this new simulation programme was very positive and comparable to previous feedback. Across all sessions (n=12) and trainees (n=5), the median Likert scores for perceived relevance, realism, and appropriate challenge were 6/7, 5/7, and 6/7 respectively. All trainees across all sessions indicated they found it useful, enjoyable, and would attend again. In particular, free text responses praised the ability to focus on a single simulated issue without the cognitive overload of the wider theatre environment experienced by new trainees, and the psychological safety benefits of simulation and debriefing in a more relaxed non-theatre setting. This appears to be a feasible and well accepted alternative to our traditional approach, with additional benefits for trainees and reduced impact on service delivery. We now intend to explore use of this approach to deliver increased SBE to the wider anaesthetic and multidisciplinary team. 1. Royal College of Anaesthetists. Simulation Strategy 2018–2023. London: RCoA 2018 2. Fletcher J, Wind A. Cost Considerations in Using Simulations for Medical Training. Military Medicine. 2013;178(10S):37–46. 3. Helyer R, Dickens P. Progress in the utilization of high-fidelity simulation in basic science education. Advances in Physiology Education. 2016;40(2):143–144.

Audit of effect of spinal diamorphine and patient outcome

Background: Intrathecal diamorphine is a popular analgesic technique for postoperative pain relief in major abdominal procedures. The maximum effect of diamorphine is seen within the first 24 h but it may be associated with side-effects such as respiratory depression, postoperative nausea and vomiting (PONV), and pruritus.1 2 Our main objective was to assess the postoperative effects of spinal diamorphine, focusing on pain relief and side-effects (PONV, respiratory depression, pruritus), compared with Royal College of Anaesthetists’ (RCoA) standards.

QI initiative to introduce a formal anaesthetic shift handover in a district general hospital

Background: International research has highlighted a number of problems in handovers. 1 Despite being identified as a key part of a patient’s journey, no standardised best practice exists.2 In our anaesthetic department, anecdotal reports of suboptimal handover practice, poor trainee survey results, and accreditation requirements all naturally led to targeted improvement. We aimed to: (1) introduce a standardised anaesthetic shift handover process compliant with Royal College of Anaesthetists (RCoA) Anaesthesia Clinical Services Accreditation (ACSA) standard 1.1.1.3 (‘there is a structured handover between shifts’)3 with a target of >75% of handovers being dated and persons identifiable; (2) undertake semi-structured interviews to test the hypothesis that the intervention: (a) led to improved stakeholder perception of handover, (b) improved perception of patient safety, and (c) better information exchange.

The perioperative management of transgender patients: a knowledge gap we can no longer ignore.

Recent years have seen an increase in the number of people openly identifying as transgender in the UK, with current estimates ranging between 200 000 and 600 000 individuals. There has also been an increase in the number of patients undergoing both medical and surgical gender-affirming treatment. There are several important, specific considerations that perioperative clinicians must be aware of when caring for transgender patients, including changes to the airway, potential respiratory and cardiovascular complications, and the management of hormone therapy. Alongside this, important general considerations include the correct use of patient pronouns and ensuring patients are admitted to correctly gendered wards. Despite the need for these considerations, the perioperative management of transgender patients is not covered in the Royal College of Anaesthetists' curriculum; to date, no national guidelines exist on the subject. This article discusses some of the key, specific perioperative considerations relevant to transgender patients, and highlights the need for national guidelines and improved education on the subject.

The perioperative management of transgender patients: a knowledge gap we can no longer ignore

Recent years have seen an increase in the number of people openly identifying as transgender in the UK, with current estimates ranging between 200 000 and 600 000 individuals. There has also been an increase in the number of patients undergoing both medical and surgical gender-affirming treatment. There are several important, specific considerations that perioperative clinicians must be aware of when caring for transgender patients, including changes to the airway, potential respiratory and cardiovascular complications, and the management of hormone therapy. Alongside this, important general considerations include the correct use of patient pronouns and ensuring patients are admitted to correctly gendered wards. Despite the need for these considerations, the perioperative management of transgender patients is not covered in the Royal College of Anaesthetists' curriculum; to date, no national guidelines exist on the subject. This article discusses some of the key, specific perioperative considerations relevant to transgender patients, and highlights the need for national guidelines and improved education on the subject.

Improving anaesthetic chart documentation

Anaesthetic chart documentation is crucial to maintaining comprehensive records relating to perioperative events. Lack of adherence to documentation has medico-legal implications, and more importantly, can negatively affect the quality of patient care. The Royal College of Anaesthetists (RCoA) and

Nasogastric tube never events during the Covid-19 crisis in the UK; fewer than predicted.

Early in the Covid-19 pandemic, the NGSIG predicted the number of sick Covid-19 patients requiring nasogastric tube (NGT) feeding in critical care and high dependency areas would increase dramatically with consequent increased risk of unrecognised misplacement leading to Never Events (NE) and/or pneumothorax. Based on our Position Paper on NGT safety1 we produced an Aide Memoire2 with NHSE/I endorsed by NNNG (National Nutrition Nurse Group), The Faculty of Intensive Care Medicine, The Intensive Care Society, The Royal College of Anaesthetists and the Association of Anaesthetists before publication2.

Editorial introductions.

Editorial introductions.

General Anesthetic and Airway Management Practice for Obstetric Surgery in England: A Prospective, Multicenter Observational Study

(Anaesthesia. 2021;76:460–471) The use of general anesthesia (GA) in obstetrics is typically avoided due to concerns of increased risks, but is sometimes unavoidable. Accidental awareness during GA (AAGA) has been previously investigated by the Royal College of Anaesthetists and the Association of Anaesthetists in 2013. This study, the direct reporting of awareness in maternity patients (DREAMY) study aimed to determine the incidence, risk factors, and sequelae of AAGA. A secondary study within DREAMY sought to describe the provision of GA, including drugs and management techniques used in the United Kingdom.