 Felly, we fed our patient through the tube and our patient died. He was at the opposite end of life to Grant. He was a grandfather, soon to be a great-grandfather. But the months of life that should have been there for him to enjoy were lost. And it happened on my watch. Yesterday and this morning we've heard the term second victim used to describe staff involved in a patient's safety incident. I have to quickly say I hate the terminology of second victim and I can understand why it makes some of the bereaved and patients who've been harmed incandescent. When we get things wrong, the patient is the first victim, but everyone who loved them and knew them is the second, third, fourth, up to several hundred victims. But it's not to say there isn't truth in the concept. I know my team from 15 years ago is still scarred by the error we made. And the patient's family forgave us far more readily than we ever forgave ourselves. So every case of nasi gastric tube misfeeding represents not only a tragedy of preventable harm to our patients, but also preventable harm to our staff. The executive summary checklist of the nasi gastric tube apps highlights what we should do. But I need to mention a couple of important points that the full version of the app says we shouldn't do. It tells us never to use air osculation as a verification method. Air osculation involves listening with a stethoscope as you inject air into the nasi gastric tube and channelocate where that faint whooshing sound of air exiting the tiny tube is coming from. Research dating back to the 1990s shows that air osculation is less reliable than tossing a coin. In test conditions over 80% of clinicians failed to detect tubes in the lungs. In England, air osculation is something we banned over 13 years ago. But when preparing for this panel, I was shocked to realise just how commonplace this method has remained in some other countries. I found materials teaching parents, teaching nurses, teaching doctors to use air osculation apparently totally unaware of the research and the risks. When I tell you I found that rather alarming and I really would urge you to take very seriously the requirement in the apps to eliminate its use, you may have to adjust the volume on the emotional dial. I'm British. I'm a nurse from a generation of relentlessly nice nurses. So please translate that into the equivalent of me sobbing, pleading and pounding on this lectern. This hasn't only been a journey of eliminating outdated methods. We sometimes worry health care is too slow to embrace innovation. But in laser gastric tube safety we've seen the opposite. With some new and expensive technology automatically assumed to be superior when it was not. Our national safety team in England and the FDA in the USA has hatchery issue warnings related to some of these technologies. And the apps also helps us understand their limitations. But the apps makes it very clear there's more to safety than just using the best techniques for laser gastric tube insertion and verifying placement with the evidence-based methods of pH strips and X-ray. It's also not giving staff the training, the equipment, the confidence to do that as well and as safely as possible. So seven years ago in England we began to emphasise the importance of education for nurses in the tricks and techniques that support testing via pH strips and education for doctors replacing the traditional X-ray interpretation method that caught my doctor out all those years ago of just checking the tip of the X-ray. Instead, it's vital we use the four criteria systematically checking the X-ray at four specific points along the laser gastric tube's path. That training can be given and assessed in less than an hour. And we've not yet seen a single X-ray misinterpretation occur when that four criteria technique is used. But it needs executive leadership, good governance, good educators, good managers to ensure no staff have been left out or left behind. And to create a fair and open culture where if we get things wrong we report them, we investigate them, we share our findings with patients and their families and we act to address the underlying causes. Professor Don Berwick says many wise things about improving the quality of health care but my favourites are around the need to bring joy into our work and he reminds us that we can't sustain improvement without it. That's difficult for patient safety because the patients we fail, like Grant, have names, pictures, stories that touch our hearts whilst the patients we've saved from harm are forever nameless and invisible. A colleague and friend of mine found a way of helping bring back a little joy that I'd like to share with you. Whenever you sit down at the favourite feast or celebration in your culture, Christmas, Eid, Thanksgiving, Hanukkah, Diwali, Chinese New Year, picture in your mind the families that might have had an empty chair. Because of all that you in the room have done and will do, and all that the panel I'm about to introduce have done and will do, there is a family that doesn't have an empty chair. They're happy, or at least happily arguing if there are anything like my family's celebrations. And the circle of chairs is still complete. So, for all of you as leaders in the room, whether as parents, patients, executives, philanthropists, clinicians, technology, politicians, civil servants, as I introduce the panel, I'd ask you to remember it's a great joy and a great privilege to be able to take advantage of the actionable patient safety solution on nasogastric tube placements and verification. Please welcome our panel. And I'm going to ask the panel to introduce themselves, but we do intend to give as much time as possible to your questions, so do please remember that via your smartphone apps you can ask questions for the panel. I would like to ask you the first question because you've so kindly shared the story of your little boy. We know you've been active in patient safety efforts since Grant died. Would you tell us a little about why that was important to you and what you've been participating in? Definitely. So, after a couple of years after Grant died, I got to thinking about the things that we had worked with the hospital that they were going to implement. And I wondered to myself, how do I know that they really actually followed through with those promises and how do I know that those changes worked? So, I called the hospital and I scheduled a meeting and that's when I met Chris. And, sorry. But when I sat there and I talked to them, I learned that they had actually implemented the changes and she was actually able to tell me that day that they knew that they had saved four babies' lives because of the policy changes they made. And through their work, I had learned that a pH strip, if it had been used to verify Grant's feeding tube placement, he might have been here today and had he lived, he'd be 10 years old in April. But when I was sitting there and after she told me that she knew four babies' lives had changed, I got to thinking, well, how can I improve that number? How can I make sure that this becomes a never event in the US? And so I then asked how I can be a part of the hospital patient safety team to make sure that changes continue to take place and to get involved with being part of that change. And so I started sitting on their patient safety committee and then through that committee and being focused on NG2 placement verification and they introduced me to Beth and the novel project that she had started up, which is looking for that gold standard, which eventually led me here to be at the Patient Safety Foundation Movement Conference because I pitched the idea that, how can we universally find a gold standard so that nobody lives the consequences I did? Thank you so much, Diana. And the story we will have today, I think, is all of us finding the babies and the adults that we can use Grant's story and the wisdom of our panel to save. There was one part of Grant's story which probably echoes with all of us in that you felt something was wrong, didn't feel listened to. Obviously it's highly important we listen to parents, to patients. But what's tragic to me is often also the clinical staff in these situations who felt something is wrong. So I've known a junior doctor who's been perhaps uncertain whether they're reading the x-ray correctly but hasn't quite followed their instinct through to asking for more expert help. I'd like to ask all of our panel in turn what more they think we can do to listen to parents, listen to patients, but listen to colleagues and listen to our own instinctive unease. Christine, perhaps? Yes, so having policies and procedures is obviously very, very important but I think the biggest thing with Grant is the signs of when a feeding tube can go into lungs, really mimic respiratory distress, gagging, sometimes even vomiting. But it's really following your clinical judgment and your intuition and really knowing that if you're putting a tube in and you're getting some form of distress then you need to stop. And we have a motto in our hospital that we use saying pause to care and we've had so many families comment on that and it is taking that minute to pause and realize this isn't working, we need to take it out, we need to try again. And I think just that message in itself, yes you need to follow the right procedure, you need to do confirmation through pH or your x-ray. But any clinical sign of distress should make you stop and until you can figure out what's going on that patient you have to assume it's that nasogastric tube or oral tube. And I really believe in Grant's case, Deanna spoke up and we didn't listen and that's what's really tough is making sure not just the parent but the clinician at the bedside. If there's not something that feels right, you take it out. David, perhaps on the perspective of also educating doctors to have that confidence, what would you like to add? Well, I think that this is a very good situation that signals to the fact that we need a better communication in every case where we have a safety problem. You have to listen to the physician, you have to listen to the patient, you have to listen to the nurse and as it was mentioned yesterday, you have to listen to the team that takes care of the individual. That is a good way to avoid errors and to avoid mistakes. And self-confidence in anyone is a very bad thing. You have to be humble enough to listen. I think communication is a big effort. So I think that's the point I hear from all my panel that modesty is a virtue in patient safety and I have a very wise but also very modest panel here, I think. Beth, do you have experience of not just teaching the technical skills but that ability to realise when you're out of your depth and something might be wrong with your own scenes? I think that all of us in clinical practice have started a procedure, whether it's an NG tube, an IV catheter or whatever and found out that things weren't going well and having that index of suspicion. I think that we start as novices not being able to recognise that and develop in our careers knowing when to take a pause, as you said. One of the biggest concerns that I have about this issue is that many of our hospitals in the United States are not even giving nurses or clinicians. We have some physicians as well in the United States placing NG tubes but they're not using evidence-based approaches to even verify placement. And in one study that we did with the novel project through Aspen, most children's hospitals in the United States use oscultation or aspiration for NG tube placement verification. PH and an X-ray were way down the road and so when a nurse takes a pause, uses critical thinking skills but doesn't use an evidence-based approach, they're still not going to get where they need to be. That's what concerns I think many of us. I'm shortly going to ask you about some of the novel technologies Beth, but I think it's worth us talking through. We actually have technology that's been around a long time. We have PH strips, which are a fairly straightforward bedside test. We've certainly been using them for more than 13 years. We find about 90% of placements can be verified. We've got clinical research that says it's very, very rare indeed under test conditions to get acidic PH from the lungs. And in practice, because of our voluntary and mandatory reporting systems, we suspect that if there is an error rate with PH strips, it's something in the region of one in 30,000. Now alongside that, we have air osculation which has no evidence-based, no reliability. Why do you think we have clinical practice that is it's so dedicated to one and somehow we've left the research evidence behind? David, would you perhaps like to first comment from the perspective of a country that perhaps hasn't got as many established protocols and then Beth and Christine from a USA perspective? Well, for example, in Mexico, I think it's very important to have guidelines. That's the first thing you need to make sure you have guidelines. In Mexico, we do not have national guidelines for placing a tube. You tend to think that it's a very simple thing that you can learn, you can put the tube, and you sometimes miss the opportunities of having guidelines. That's the first point. The second point is it's not compulsory to report side effects of a nasogastric tube. You only report them when you have a severe and a threatening situation, actually when there is the risk of the person dying. But that's not the only side effect. You have other side effects when you place a tube. So I think it's important. We're now in the process of developing national guidelines with the Nutrition and Gastroenterology Association and also to make compulsory reports of side effects. It's not only the big mistake, but the ones that are recovered because most of the times, for every time that you have a death, you probably have a significant number of complications which delay the length of the stay of the patient, develop pneumonia, develop resources, and it's very costly. So I think it's very important to the projects which you have, the novel and the Aspen protocols. And we have made, for example, in the recent years, in the last year and a half, we have made a study in which we have a protocol at the institution. And that has made a big difference, not only in the side effects, but in the length of stay and the percentage in which you achieve the results of a good natural gastric feeding. What is the purpose of putting the tube and what is the result you can measure after you place the tube? Thank you. So David has the challenge of establishing protocols and good practice. In the USA, you've probably got the challenge of changing what is established, normal practice, if not good practice. Any advice to everyone in the room on how to go about that? Well, as most people can probably guess in the room, this went down as a sentinel event. And so that I was pretty much pulled in. I'm a clinical nurse specialist, so my specialty is pediatric cardiology. But because this event happened in our area, I was pulled in to then basically change our policies and procedures related to nasal gastric feeding. And that's when when I did the literature review, it was very clear that auscultation was a very old practice. And insertion of an NG is not the only example in our health care system in America where we sometimes hold on to old practices because it's what we learned. I'm going on 30 years now of being a nurse and I can tell you that that's how I was taught 30 years ago in nursing school. And some of these things take much longer to change. And I do think because it's not a mandatory reportable event. And when you look in the literature, there's always a range of misplacements and it's not a very good range. It's anywhere from three to 20%. And part of that is because it's not reportable, we don't have a lot of data and numbers around it. So we did change the policy. It was the right thing to do. But I do have to say is even when we took that auscultation out, I really had to go to a lot of our nurse managers. I had to go to our home health agencies and I had a task force that I had recruited. So I really should say we, we had to do all these things because there was a lot of resistance to changing that policy. So when we went to go educate to implement the policy, we had to take a step back. And what we did is we told Grant's story. And that was really powerful. It was really hard for people to hear, but they realized this is the right thing to do and it's also what the literature supports. And so my biggest thing is I don't want it to take a Sentinel event to make a change. I hope most people in this room, you don't have to go through that because it's really hard. It's hard on everybody. And but the patient and family is the one that it's all about. So it's really bringing it back to the patient and the family, you know, to make that change. But it wasn't just about changing the policy and procedure. It was really having to do, go to the leadership and tell them why we were doing this and tell them the story of Grant as well as some other patients that had misplaced tubes that weren't harmed as significantly. And this is why we have to do this. I think on a national level, your experience would be mirrored among many hospitals in the US. Part of the issue with measuring pH in the United States is that it's a CLIA event, a point of care testing that requires annual competency and color chart reading and all of these kinds of things. There are other products in the market that will circumvent that and I think you heard about one yesterday. But essentially, there are barriers within institutions because they don't want to go through the whole area of point of care testing. In NICUs in particular and in the United States, 60% of children who have an NG or orogaster tube are in a NICU. There are many people that believe, including me by the way, that pH would not work in that environment. And we actually did finish a study, the novel project did. It was done at my hospital. But 97% of the time when a pH is done on a neonate, we were able to get a level below five and say that we did not need an x-ray or another method of verification, which for us would be an x-ray. So I think that there are really attitudes. I think most people know that pH is the right way to go and certainly anyone who's followed this literature would follow the UK example of what they've done over the years and know that their track record is really quite stellar in this area. But it's really more an attitude and convincing people that this is even an issue. We did submit a multi-center study to the National Institutes of Health in the US and the reviewers were not convinced that this is a problem. So I think we're kind of at that level and I've heard from two of the panelists that we don't have a mandatory reporting system and in fact there's a very strong impetus not to report sentinel events in the United States due to issues about litigation and that is tripping us up in this area as well. But if we want to get to zero, we have to have measures how to implement them. If not, we're not going to get to zero. So we need that. And I would like to make a comment. In adult patients in which you have people with dementia or people with a cerebral vascular accident and they don't get the reflux the same way, the gagging, the coughing, it's a particular risk factor, a very important one. And the other issue is that a lot of patients are put on pump inhibitors. And by the time you want to put a nasal gastric tube or nascentaryl tube, the measurement of the pH is affected by the use of these drugs. And then you have to remember other ways of how to measure it, including the x-ray which you showed and which I think it's very important to disseminate the knowledge of the important point which you need to check in the x-ray. It's not only seeing the x-ray and seeing the tube in the left side and saying it's in there. And I just, I did want to just add to what Beth said was really important about the point of care. And on that task force, we actually had our point of care manager from the laboratory. And I have to say, this is the other thing too and you want to make change is have the right people at the table. She was, that was not an issue. She was like, if this is what we need to do, we're going to bring pH paper in. And she made that happen. And she wrote that piece of the policy and that was just wonderful to have such a team player on that. This is not going to be a barrier, so. I'd like to add too. I know that a lot of organizations are resistant to one of the other items that we've listed. So pH being the first go to and x-ray being the second. And I know that there's the concerns with the radiation and stuff and this is going to sound horrible to say but I always tell them, I'd rather have a radiation baby than a dead one. Because I can at least live and grow with my child with going through radiation therapy and have a life and get to see and know him. I got 11 days with my son because I wasn't an option at the time. So my memories are wishful memories. What would he have been like? What would be his favorite color? What sporting activity would he have liked? That's all in my imagination. Very powerful message, Deanna. Thank you. I think to pull together some points from the channel, from the panel. We know these are rare events but it's also a very everyday practice. It's the points we're making in terms of actually finding out if you try pH paper, whether it is adults on PPI's or whether it is little babies in neonatal intensive care units, you will probably find you get an acidic pH more often than perhaps the naysayers would tell you. You do have X-ray as a second line verification and when it's needed, it's needed. We should never X-ray unnecessarily. But the day-to-day process of actually checking our doctors have those skills, our nurses have those skills is something that's quite easy to measure because that's something that's carried out day-to-day. Ananna, Christine, you have some interest in electronic medical records, as I know the room does more generally, not just a way of auditing good practice but helping remind people what good practice is in relation to nasiogastric tubes. Yes, so when we... I really do like our policy and procedure team in our hospital. You know, there's been, I'd say over the last six or seven years, really good changes and once again, it's not just writing the policy but it's also about educating and implementing which includes what you're going to put in your electronic medical record. So in our electronic medical record, when a nurse or provider inserts a nasiogastric or oral gastric tube, they are prompted on the confirmation and if they've done it by pH or X-ray and also where the marker point is on the nose and so that in the chart, it should be easily referenced to where the marker is, also any signs of distress as well too. Now, saying that, this work, it's never done, right? I mean that it's always maintaining and we recently, it's strange how things happen but there's a couple of things that happened before I came to this, the patient safety movement and I think it just reminds us of how our work is never done and how we always have to stay on top of it but we had a misplaced tube in our pediatric ICU. The tube was actually put down for decompression which is basically not for feeding. You're actually, it's to take liquid out of the stomach and remove gas and it actually had been inserted in the lung and the nurse did get a gastric aspirate, however she didn't test it with the pH because in our electronical medical record, the options is gastric aspirate and then a separate optrin for pH and so an X-ray was taken and that's how it was found and the tube was removed and there was no harm done to the patient. However, it just made me realize, okay, we have to change that in electronical medical record having gastric aspirate separate from the pH can be confusing to our staff and in this case, the nurse did not get a pH. David, and then we'll ask a little more about new technologies I think. I think it's very important to remember that the natural gastric tube can be put in place for aspiration, as Christine was saying, but when it's used to fit the patient, that is the most risky part of the procedure and one has to make a difference between why are you putting the tube and what you're going to pursue with the procedure. Very helpful. Beth, I know your novel project has tried to also look at new technologies and not every new technology has been a true dawn. I wonder if you can tell us a little more about that work. So the novel project stands for new opportunities for verification of aneral tube location and it was started by the American Society for Parental and Internal Nutrition in 2012 and we specifically seek out, we have 14 odd members of physicians and nurses from all over the United States, Canada and Australia and we have a nurse in Brazil. And it was specifically started to disseminate best practice, kind of following the United Kingdom model and also to work with inventors and industry to develop technology. We do not think that there is a one size fits all approach for this and currently the novel project focuses on pediatrics and neonates but it's going to expand to adults as well but we really seek out industry members to give them feedback and things because the technology that's out there right now doesn't quite hit the mark for pediatrics and there was a recent FDA alert about one product that actually has been the subject of the National Health Service patient safety alert system in the past. And so we do need very simple technologies to be developed so that a staff nurse at the bedside could verify NG2 placement and then in real time reconfirm placement. So it's one thing to get the tube in but it's another thing to make sure it stays where it's supposed to be and this really is needed for I think actually both adults and pediatric patients. I'd like to add to that. One of the things that when Grant's feeding tube was put in the nurse actually turned to me when I was asking her all the questions about her placement verification. She told me she said you know you're going to have to learn how to do this when you go home because there's a possibility he could pull out his feeding tube. So those technologies not only have to be for staff members at organizations but it also has to be for a family member who might be put on call to put it in. Very powerful. What we were keen to do was spend as much time as we could on questions from the audience which happily have come in at some good speed. A lot of these do relate to education and I just wanted to do say one thing that's probably a lead up to when you hear Matthew Syed speak this afternoon. That there's an aspect of how our minds work called cognitive dissonance which means if we've actually done something for a long time and believed in it and if we believe we're good clinicians and good people it's very hard to believe that the old fashioned thing we were doing was wrong and that has quite a profound effect in change. It's perhaps one of the reasons why it's easier to change to exciting new technology than it is actually to change to something we could have been using 13 or 15 years ago because it makes us question our own practice and our own values and what we've done. Within that we've got questions that are very much on this critical question and tie back to the session we heard yesterday on patient safety as part of curriculums. What would your advice as a panel be in terms of considering someone in the room who has their own hospitals or hospital chains who is trying to change policy, change the training they provide for their nurses, doctors, parents. Where would you suggest they start? Can I share my story? I have learned through Children's Hospital that it was very impactful for their staff and I actually had a full 360 moment one time when I was doing rounds when the hospital was initiating their target zero which is much like this, zero harm by 2020. And when we were rounding with the staff, I noticed there was a patient on a feeding tube so of course I started asking that nurse very leading questions, how did you do your placement? How do you know it was right? And so she's telling me the techniques that they use that I already know that are supposed to be in place so it was nice that she's using them. And as I'm asking her a few more questions she turns to me and she says, you know, several years ago we lost a little boy. His name was Grant and he died because a feeding tube was put in wrong. And I looked at her and I said, thank you. You have just shared my story to me and validated that the reason his story is used is powerful and useful. So use his story is the first thing I'll say because having that patient's story really does emphasize the need and it puts a face to the reason why those policy changes are needed. And I think that certainly a story we hope to make sure you all know how to access and use after the conference. And I just wanted to add to the other thing that Deanna does is University of Northern Colorado has her come every semester and incorporate her in teaching the BSN students to tell a story. And it's really, it's about Grant's story but it's really about listening to families and it's about patient family engagements. You know, so much was taught yesterday at that panel. And I think that's a wonderful way to adapt into curriculum. Being a clinical nurse specialist I have a lot of different roles but one of the things I've really gotten involved in the last five years is high fidelity simulations. And I do think that simulations are a really good way of teaching things that can happen to a patient and doing a misplacement and seeing how the team responds. And that way it's not just about, we keep talking about collaborative education and our high fidelity simulations it incorporates all of our team members. Our physicians, our pharmacists, our nurses, our RTs. And when you do that debriefing and if you do a really good debriefing it's really powerful and it helps so much with those team dynamics but then you can also address things like this with patient safety concerns and why they're important. So I highly recommend if you're able and you have access to high fidelity simulation to be able to use that in the curriculums as well too. David, would you like to comment perhaps on medical training as well building on giving doctors a story? No, I think this is very important. I would like to add that we put a lot of intravenous catheters at the institutions and we have a team that goes around and sees that you don't get an infection, you supervise, et cetera. I think this cooperative team which includes the nurse, includes the nutritionist, includes the resident, the physician is very important to have a team that should go around the institute or the hospital and see the amounts of tubes you place in a week and see the status that these tubes have. I think that surveillance is very important to the safety. We tend to forget. We look to the vesical catheters, to the intravenous catheters but we don't think the same way when you put the nasogastric tube or nascenteral and you also mentioned, Christine, the fact that it's not only putting the tube but what's happening the days after you put the tube because you can have complications not only in the placement of the tube but in the days after you put the tube. So recently I made a video on NG2 placement verification. It will be on the Aspen website, it's a YouTube, it'll be a YouTube video and we are going to allow our parents to download it. The Feeding Tube Awareness Foundation in the US is going to use it and it actually has a sim lab aspect to it but it also has actual patients and it shows me almost getting kicked by a 10-year-old darling child. And so it's very real world as well but I think education of healthcare professionals using experienced people and best practices is a very important thing and then I will dovetail on to something you say. I am part of a nutrition support team and we do have a team of people and part of the nutrition support team there's an internal access team because we do see that the vascular access team that looks at our central lines has made a huge improvement in central line complications and the internal access team looking at feeding tubes not just nasogastric but the gastrostomy tube that gets placed in a child that has a TE fistula and things like that. We deal with those as well and I think that's very important. And I think the parents is very important because many times the patients go home and they continue with the process of feeding. It's not only at the hospital but at home and I think getting the parents involved into the process is very important. I'm aware we're coming close to time and we're definitely going to let Deanna have the last words. In terms of the questions we haven't been able to get to some are quite technical why we're recommending what we recommend you know why, how will we stop tubes being removed how would we worry about subsequent verification. I think between us, between the full version of the apps the Aspen materials some materials from the UK that I'll tweet we should be able to answer most of the technical questions offline. We've also got some interesting challenges for new technology we've had suggestions as to how much does ultrasound and sonography have a role to play. I'm not going to attempt to answer that from the panel but the panel will I'm sure pick up questions and I know Beth is particularly knowledgeable about some of the potential for new technologies. But we would like to end as we started and Deanna you have a right to challenge all of us and all of the room and tell us what you want us to do to make sure we protect other people's babies other people's grandfathers other people's loved ones. One of the things that I learned through the process is that when Chris was rewriting the policy she had to look to see what literature was out there. And then in reviewing that literature discovered that you know what they had currently in place was incorrect. So what I have learned you know that was a starting point but I've learned that most organizations they only know that there's a change needed if they read the literature. So we have spent a lot of time creating this app and so I implore you to go to your organizations or people you know in organizations to get current on the literature to read our app and understand the importance of being current and using the technologies that are currently advised and to discourage the ones that are no longer valid or have been invalid for a long time. Because when with the novel project we learned that so many hospitals were still using an antiquated process because they did not read the current literature. So that is my challenge to you as I implore you to go back and encourage and enforce that everyone needs to be current and read the app that we have designed so that everybody can be doing it the right way. And one thing to add on to that as well too the other thing is with we're actually doing a current revision right now of our policy and we've actually made it a yearly review. So usually most of our policy procedures are every three years because of all the work that's been done in this and the risk to our patients we do it every year but our neonatal intensive care unit brought a new tube in and the new tube when I was reading the packet insert the packet insert calls for auscultation, for confirmation. So I would just ask you as well when you're picking products and looking at products be aware of what the package insert is because a lot of staff and doctors when they're inserting they could just go to that packet insert and bypass the policy. So it made us realize that we have to be we really have to be think this new tube in that packet insert so but when you ask that question in the beginning of why auscultation is still used another barrier in the way is the products that are being made include the wrong information. To add if you're here as a manufacturer get current. Unless we have another burning word I would like very much to have left Diana the last word so it reminds me to say thank you so much to the panel for everything they have done will do. I think you've been given your orders as a room and I know you'll take those orders on board. Thank you very much indeed.