advanced airways just-in-time training
DESCRIPTION
Dr. Akira Nishisaki (Children's Hospital of Philadelphia) talks about A Just-in-Time Training study on pediatric advanced airway skills at the CHOP PICU.TRANSCRIPT
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Advanced airway management and Just-in-Time training for critically ill
infants and children
Akira Nishisaki, MD, MSCE
Anesthesiology and Critical Care Medicine The Children’s Hospital of Philadelphia
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Disclosure
Ongoing support:
• Laerdal Foundation Center for Excellence
• Endowed Chair Fund, Critical Care Medicine, CHOP
Completed support:
• AHRQ HS016678-01
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Objectives• Upon completion of this lecture, you should be
able to:
-Describe the current safety and quality challenges
-Discuss Just-in-Time training as a potential approach to improve safety and quality
-Describe the challenge and benefit to conduct multi-divisional multi-discipline projects
in pediatric airway management outside the OR (ED, NICU, PICU, CICU)
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Background
• ER video clip
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Advanced Airway Management
• Tracheal Intubation is a mainstay of advanced airway management
• Most commonly done as a part of general anesthesia
• Placement of tracheal tube to improve oxygenation and ventilation
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Outside view Anatomical view
Tracheal Intubation
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Pediatric Airway ManagementEpidemiology—Emergency Department
• Report from National Emergency Airway Registry(NEAR) including 11 EDs in 6/1996-9/1997
• Pediatric patients: 156/1129 ( 14 % )• Wide age range: 0-2 year: 25%, 12-18 year: 40%• Trauma related: 49%, Medical: 51% (Head trauma and Seizure are leading causes)
• 17% had technical issues
Sagarin MJ Pediatric Emergency Care 2002
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Age vs. Method
Sagarin MJ Pediatric Emergency Care 2002
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Condition needing intubation
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Adverse Events
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• How about the “New 21st Century” with RSI: Rapid Sequence Intubation?
Pediatric Airway Management
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• A single center study at CHOP from 2006-2008
• Retrospective chart review including transport team documentation
Patients from referral hospitals
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Patients needing intubation
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Methods
• Is sedation + paralytic=RSI: Rapid Sequence Intubation?
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Outcomes: TIAEs
**
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Verification Study
• Ongoing as a QI project at CHOP (led by A Donoghue)
• Likely to report MUCH HIGHER Adverse events detected by video review
• A separate study verified video review is highly reliable (high reproducibility)
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NICU Airway Management
Falck et al. Pediatrics 2003
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NICU Airway Management
Falck et al. Pediatrics 2003
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L&D intubations: Video Analysis
O’Donnell, et al. Pediatrics 2006
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L&D intubations: Video Analysis
30 sec
20 sec
O’Donnell, et al. Pediatrics 2006
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Airway Management (!?)
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PICU Airway Management
• National Emergency Airway Registry for Children (NEAR4KIDS)
• Started locally at CHOP as QI project
• Expanded to 14 PICUs and 1 NICU, 2 EDs through PALISI network
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NEAR4KIDS project
• What is new?
-Clear intention to IMPROVE outcomes
-Use standardized operational definitions
-Structure and clear data points
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• An “ENCOUNTER” of advanced airway management refers to complete sequence of events leading to a placement of an advanced airway. Encounter is completed when a stable airway is achieved and no further immediate airway management is needed.
• A “COURSE” of advanced airway management refers to ONE method or approach to secure an airway AND ONE set of medications (including pre-medication and induction). Each COURSE may include one or several "attempts" by one or several providers.
• An "ATTEMPT" is a single advanced airway maneuver (e.g. tracheal intubation, LMA placement), beginning with the insertion of a device, e.g. laryngoscope (or LMA device) into patient's mouth or nose, and ending when either the device (e.g.laryngoscope) is removed or the advanced airway is placed
Operational Definitions
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Relationship of Encounter, Course and Attempt
ENCOUNTERAttempt #1
Attempt
Attempt #3Attempt #2
Course
Course
Course Attempt #1 Attempt #2
Example: Primary Oral intubation followed by Three Attempts of Oral to Nasal Tube Change (failure), followed by Two attempts of Oral Intubation (Primary)
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Outcomes of interest
• Process of care: Multiple attempts (> 2 attempts)
• Outcomes: Successful airway management or Tracheal Intubation Associated Events (TIAEs)
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Tracheal Intubation Associated Events (TIAEs)
• Cardiac arrest-patient survived/dead• Esophageal intubation-without immediate recognition• Vomit with aspiration• Hypotension, requires intervention (fluid, meds)• Laryngospasm• Malignant hyperthermia• Pheumothorax/ pneumomediastinum• Direct airway injury
• Esophageal intubation with immediate recognition• Vomit without aspiration• Hypertension, requires meds• Mainstem intubation without immediate recognition• Epistaxis• Dental/lip trauma• Medication Error• Dysrhythmia (includes sustained bradycardia)• Pain/Agitation, required additional meds AND delay in intubation
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A single center prospective observational studyCHOP PICU for 14 monthsOne encounter in every 2.3 days
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Landscape of our practice
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Provider and Outcomes
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Tracheal Intubation Associated Events (TIAEs)
Observed in 20%
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0.19†11 (6.8%)5 (13.2%)Etomidate
0.53†33 (20.3%)6 (15.8%)Ketamine
0.20†100 (61.4%)19 (50.0%)Fentanyl
0.93†70 (42.9%)16 (42.1%)Midazolam
Sedative/narcotic use
0.006†94 (57.7%)31 (81.6%)Vagolytic use
0.84†153 (93.9%)36 (94.7%)Paralytic use
0.50†14 (8.6%)2 (5.3%)Method (Nasal)
0.6†◊36 (22.4%)10 (26.3%)Time (Night:23:00-6:59)
0.89†88 (54.0%)21 (55.3%)First half of academic year
Practice
0.0001*1 (IQR: 1-2)2 (IQR: 2-3)Number of total attempts
0.33†♦95 (58.6%)19 (50.0%)First Attempt by Fellow
0.24†♦52 (32.1%)16 (42.1%)First Attempt by Resident
Provider
0.61†74 (45.4%)19 (50.0%)Sign of potential DA
0.82#†24 (14.7%)6 (16.2%)History of DA
0.62†45 (27.6%)9 (23.7%)Elective
0.20†47 (28.8%)15 (39.5%)Ventilation failure
0.32†63 (38.7%)18 (47.4%)Oxygenation failure
0.37*17 (IQR: 9-37)13.6 (IQR: 7.3-25)Weight
0.23*48 (IQR: 14-144)38 (IQR: 5-108)Age
p-valueNo TIAE (n=163)TIAE (n=38)Patient
Bold: p value<0.05
* Wilcoxon rank-sum, † Chi-square test
# One missing data in TIAE group; ♦One missing data in No TIAE group◊ Two missing data in No TIAE group
Table 7. Univariate analysis for Patient, Provider, Practice variables and TIAEs
Number of Attempts
Vagolytics use
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Pediatric Advanced Airway Management
Safety of intubation in PICU
Provider Characteristics•DisciplineTechnical Behavioral-teamwork
Patient Characteristics•Severity of illnessPresence of Difficult Airway
Practice CharacteristicsDrugsTechniques
Underlying system
Culture
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Equipment, Medication, Plans
Psychomotor and Teamwork Skills
Outcome
PracticeProvider
Reasons for Intubation Patient condition
Patient
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Patient Factors
401 Encounters from CHOP PICUs
Nishisaki, et al. Anesthesiology 2009
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Provider Competence
0.0819%29%Tracheal Intubation Associated Events (%)
<0.00193%53%Overall Success (%)
<0.00177%40%1st Attempt Success (%)
<0.00181%22%Participation (%)
p-valueFellowResident
Presented at Annual Congress, SCCM 2008
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Technical Skill Training
Konrad C et al. Anes Anal 1998;86:635-639
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Simulation Study for learning
*
T1 is longer than the subsequent intubation course
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Simulation Study for learning
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Leone TA. J Pediatrics 2005
Number of intubation
Black : Attempt
White: Success
Overall success rate dropped from 60% to 32%
Number of attempts and success per trainees during residency
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Method: Approach
Initial Course (n=586) Last Course (n=586)
Laryngoscope 571 (97.3%) 563 (96.1%)
LMA 5 (0.9%) 5 (0.9%)
LMA+Fiberoptic 1 (0.2%) 1 (0.2%)
Fiberoptic bronchoscopy 0 (0%) 2 (0.4%)
AirTraq 7 (1.2%) 11 (1.8%)
Glidescope 2 (0.4%) 3 (0.6%)
Initial Approach (Course) is not always the successful approach
CHO PICU Airway—586 Encounters from 8/2008-7/201147 Encounters (8%) required > 1 Course
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Encounter with 1 course
Encounter with >1 course
P-value
Number 539 (92%) 47 (8%)
Age 4 yr [1-11] 1 yr [0-7] 0.016
History of difficult Airway 5% 23% <0.001
Number of attempts 1 [1-2] 3 [2-5] <0.001
TIAE (%) 14% 34% 0.001
Method: Approach
Patients (Encounters) with >1 Course are more challenging cases!
TIAE: Tracheal Intubation Associated Events
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Method: ApproachC-Collar study
Study participants: N=26 16 Pediatric Transport Nurses 6 Pediatric Critical Care Fellows 4 Pediatric Emergency Medicine Fellows
Previous experience in pediatric intubation Mean 3.8 years Standard Deviation 2.0 years
Nishisaki, Donoghue, et al. Pediatric Emergency Care 2007
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Result: Primary outcomeTime to intubation
Seconds
(mean+/- SD)
Maximal A-P cervical angle movement
(mean+/- SD)
Non-restriction 29.0 +/- 12.2
(27.2+/-7.0)
2.39+/- 2.56
C-collar protection
33.0+/- 17.4
(29.6+/-7.7)
2.65+/- 1.79
Manual in-line immobilization
33.0+/- 17.1
(29.9+/-7.1)
0.85+/- 1.05*
( ) single successful intubation attempt* p<0.001
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Result: secondary outcomesWas any C-spine protection associated with more difficult laryngeal visualization?
Cormack scale
Grade 4 Grade 3 Grade 2 Grade1
No restriction 0 0 12 40
C-collar 0 0 32 20*
Manual
in-line0 0 14 38
* p<0.01, compared to other c-spine protection * p<0.01, compared to other c-spine protection method respectively respectively
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“Houston, we have a problem!!”
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CVC Dress Rehearsal
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Study Transition
• November 2008 – April 2009– Implemented as QI initiative
• May 2009– Obtained IRB approval as an exempt
research study “Effectiveness of just in time education on improving knowledge and increasing consistency of clinical practice skills in Central Venous Catheter Dressing Changes”
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• Design: Prospective
• Setting: Inpatient units, PACU, OR, Sedation/Radiology, Outpatient Oncology clinic
• Population: Nurses with varying levels of experience from above units
Methods
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CVC Dress Rehearsals will improve nurses’:
• Confidence
• Knowledge
• Psychomotor performance on manikins
• Operational performance on patients
CVC Dress Rehearsals will have a positive impact on CLABSI rates
Hypothesis
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Educational Approach
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Outcome Measures
• Knowledge and confidence– pre/post training questionnaires
• Operational performance on manikin– skills checklist
• Operational performance on patients – Direct observations
• CLABSI incidence rate
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Dress Rehearsal
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525 Nurses Participated in CVC Dress Rehearsals
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Confidence Improves
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True and False Results
Knowledge of the Policy Increased after Dress Rehearsal
P<0.0001
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Corrective Prompts
P <0.001
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Performance on Manikins
Original Train to Excellence
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Performance on Patients
% of Nurses requiring “prompts”
Observations of Dressing Change on 1673 patients P <0.001
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CLABSI Rates Decrease!
Rates per 1000 Line Days
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CLABSI Rates Decrease!
AfterImplementation
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CVC Dress Rehearsals improved nurses’:
• Confidence
• Knowledge
• Psychomotor performance on manikins
• Operational performance on patients
CVC Dress Rehearsals had a positive impact on CLABSI rates
Conclusions
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• A multi-disciplinary simulation-based training plus refresher resident skill training
• Primary outcome: First attempt success by Residents
• Secondary outcomes: Overall success, incidence of tracheal intubation associated events
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202 sessions held during 15 months (June 2007-August 2008)
Participated by:
78 Residents (Median 3 times, range:1-6) 122 RNs (Median 1 time, range: 1-6)
65 RRTs (Median 2 times, range: 1-10)
Just-in-time Pediatric Airway management study
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Just-in-Time simulation: Resident
Age (year) 29.8±3.8
Sex Male
Female
26 (33%)
52(67%)
Discipline Pediatrics
Emergency Medicine
54 (69%)
24 (31%)
Training Level(postgraduate year:PGY)
PGY-1
PGY-2
PGY-3
PGY-4,5
4 (5%)
48 (62%)
20 (26%)
6 (8%)
Previous Intubation
None
1-5
6-10
11-20
>20
4 (5%)
36 (46%)
7 (9%)
7 (9%)
24 (31%)
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4060
8010
012
014
0
0-1 0-1 0-1≥2 ≥2 ≥2Technical Behavioral Total
Performance Score
Number of simulation-trained providers in a PICU bedside airway team
P=0.13 P=0.057 P=0.012
Airway team performance during actual PICU intubationteam with ≥ 2 JIT-simulation trained members vs.
team with < 2 JIT-simulation trained members
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Non-trained residents vs. trained residents
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Pre-intervention phase vs. Intervention phase
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Hot Topic
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NEAR4KIDS Multicenter Project
• A total of 15 PICUs participate
(Brown Univ and Central California the newest)
• A total of 1206 Courses, 1116 Encounters
(June 2010-Aug 2011)
• All sites have reviewed and approved compliance plan (Calvin Brown, Akira)
• Data quality review ongoing every 1-2 months
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Encounters per month0
5010
015
0F
req
uen
cy
June 2010 Jan 2011
Encounters per month
July 2011
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Percentage of the course requiring >2 attempts
Site
010
2030
4050
Per
cen
tag
e o
f th
e co
urs
e>2
atte
mp
ts
1 2 3 4 5 6 7 8 9 10 11 12 13
Mean=14%
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Benchmarking: Percentage of TIAE
Site
010
2030
4050
Per
cen
tag
e o
f T
IAE
1 2 3 4 5 6 7 8 9 10 11 12 13
Mean=23%
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Quality Improvement Study Design
PreparationIRB
Site training NEAR-4-KIDS data collection
24 months 3-6 months3 monthsD
ata analysis
3 year schedule
Site A
Site CSite B
Site ESite D
Site Z
NEAR beta phaseIntervention
QI bundles and Intervention with PDSA cycle
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ABP MOC Part 4: 25 pointsProject: Multi-Center NEAR4Kids QI
Project Leader and NEAR4KIDS Edu Committee:• Review and assess individual site
Local leaders = Site PI:• Committed and responsible to keep site
physicians on board• Responsible tracking that member has completed
requirements (attendance at meetings, etc)• Responsible for signature of member Attestation
form
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Participant requirements:
1. Commitment to support QI project
2. Commitment for accurate data collection with high compliance
3. Participation in mandatory education
-ppt based education, educational seminar, QI webinar meetings
4. Complete “Attestation Form” after at least 1 year of participation
ABP MOC Part 4
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Multi-divisional multi-discipline project
• Airway management seems “quite different” in Patient, Provider and Practice perspective in ED, NICU, Cardiac ICU, and PICUs.
• Can we talk in a same language?
• Will this improve our process of care and patient outcomes?
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PICU: 45 beds
NICU: 80+ beds
CICU: 24 beds
Emergency Dept
The Children’s Hospital of Philadelphia
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Summary• Airway management outside the OR is frequently associated with
complications
• Risk factors can be categorized as Patient, Provider, and Practice elements
• Just-in-Time training plus Train-to-Excellence (Mastery Learning) may be a key for success
• Bundled approach will be necessary to improve safety in airway management
• Horizontal (multi-center) and Vertical (multi-divisional) approach may be helpful
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• Respiratory Dept: RRTs, Susan Ferry, Rita Giordano, Shawn Colborn
• Simulation Center: Jessie Leffelman, Dana Niles, Stephanie Tuttle
• Emergency Medicine: Hannah Carron, Aaron Donoghue
• PICU: PICU Residents, Fellows, Attendings, Bob Berg, Vinay Nadkarni
• EXPRESS, PALISI & NEAR4KIDS Network
Acknowledgement
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