Advanced Airways Just-in-Time Training
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This document discusses pediatric airway management and Just-in-Time training. It begins with objectives of describing current safety challenges, discussing Just-in-Time training as an approach to improve safety, and describing challenges of multi-disciplinary projects in pediatric airway management outside the operating room. Background information is then provided on airway management epidemiology and adverse events from studies. Just-in-Time simulation-based training is described along with outcomes showing improved resident performance and team performance. An ongoing multicenter study collecting airway management data from multiple pediatric intensive care units is also summarized.
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Advanced Airways Just-in-Time Training
- 1. 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
- 2. Disclosure Ongoing support: • Laerdal Foundation Center for Excellence • Endowed Chair Fund, Critical Care Medicine, CHOP Completed support: • AHRQ HS016678-01
- 3. 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)
- 4. Background • ER video clip
- 5. 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
- 6. Outside view Anatomical view Tracheal Intubation
- 7. Pediatric Airway Management Epidemiology—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
- 8. Age vs. Method Sagarin MJ Pediatric Emergency Care 2002
- 10. Adverse Events
- 11. • How about the “New 21st Century” with RSI: Rapid Sequence Intubation? Pediatric Airway Management
- 12. • A single center study at CHOP from 2006- 2008 • Retrospective chart review including transport team documentation Patients from referral hospitals
- 14. Methods • Is sedation + paralytic=RSI: Rapid Sequence Intubation?
- 16. 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)
- 17. NICU Airway Management Falck et al. Pediatrics 2003
- 18. NICU Airway Management Falck et al. Pediatrics 2003
- 19. L&D intubations: Video Analysis O’Donnell, et al. Pediatrics 2006
- 20. L&D intubations: Video Analysis 30 sec 20 sec O’Donnell, et al. Pediatrics 2006
- 22. 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
- 23. NEAR4KIDS project • What is new? -Clear intention to IMPROVE outcomes -Use standardized operational definitions -Structure and clear data points
- 24. • 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
- 25. Relationship of Encounter, Course and Attempt ENCOUNTER Attempt #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)
- 26. Outcomes of interest • Process of care: Multiple attempts (> 2 attempts) • Outcomes: Successful airway management or Tracheal Intubation Associated Events (TIAEs)
- 27. 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
- 28. A single center prospective observational study CHOP PICU for 14 months One encounter in every 2.3 days
- 29. Landscape of our practice
- 31. Tracheal Intubation Associated Events (TIAEs) Observed in 20%
- 32. 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
- 33. Pediatric Advanced Airway Management Safety of intubation in PICU Provider Characteristics •Discipline Technical Behavioral-teamwork Patient Characteristics •Severity of illness Presence of Difficult Airway Practice Characteristics Drugs Techniques Underlying system Culture
- 34. Equipment, Medication, Plans Psychomotor and Teamwork Skills Outcome Practice Provider Reasons for Intubation Patient condition Patient
- 35. Patient Factors 401 Encounters from CHOP PICUs Nishisaki, et al. Anesthesiology 2009
- 36. 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
- 37. Technical Skill Training Konrad C et al. Anes Anal 1998;86:635-639
- 38. Simulation Study for learning * T1 is longer than the subsequent intubation course
- 39. Simulation Study for learning
- 40. 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
- 41. 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 8/2008-7/2011 47 Encounters (8%) required > 1 Course
- 42. 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
- 43. Method: Approach C-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
- 45. Result: Primary outcome Time 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
- 46. Result: secondary outcomes Was 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-line 0 0 14 38 * p<0.01, compared to other c-spine protection* p<0.01, compared to other c-spine protection method respectivelyrespectively
- 47. “Houston, we have a problem!!”
- 49. 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”
- 50. • Design: Prospective • Setting: Inpatient units, PACU, OR, Sedation/Radiology, Outpatient Oncology clinic • Population: Nurses with varying levels of experience from above units Methods
- 51. 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
- 53. Outcome Measures • Knowledge and confidence – pre/post training questionnaires • Operational performance on manikin – skills checklist • Operational performance on patients – Direct observations • CLABSI incidence rate
- 54. Dress Rehearsal
- 55. 525 Nurses Participated in CVC Dress Rehearsals
- 57. True and False Results Knowledge of the Policy Increased after Dress Rehearsal P<0.0001
- 59. Performance on Manikins Original Train to Excellence
- 60. Performance on Patients % of Nurses requiring “prompts” Observations of Dressing Change on 1673 patients P <0.001
- 61. CLABSI Rates Decrease! Rates per 1000 Line Days
- 63. 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
- 64. • 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
- 65. 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
- 66. 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%)
- 67. 406080100120140 0-1 0-1 0-1≥2 ≥2 ≥2 Technical 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 intubation team with ≥ 2 JIT-simulation trained members vs. team with < 2 JIT-simulation trained members
- 68. Non-trained residents vs. trained residents
- 69. Pre-intervention phase vs. Intervention phase
- 70. Hot Topic
- 71. 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
- 72. Encounters per month 050100150 Frequency June 2010 Jan 2011 Encounters per month July 2011
- 73. Percentage of the course requiring >2 attempts Site 01020304050 Percentageofthecourse>2attempts 1 2 3 4 5 6 7 8 9 10 11 12 13 Mean=14%
- 74. Benchmarking: Percentage of TIAE Site 01020304050 PercentageofTIAE 1 2 3 4 5 6 7 8 9 10 11 12 13 Mean=23%
- 75. Quality Improvement Study Design Preparation IRB Site training NEAR-4-KIDS data collection 24 months 3-6 months3 months Dataanalysis 3 year schedule Site A Site C Site B Site E Site D Site Z NEAR beta phase Intervention QI bundles and Intervention with PDSA cycle
- 76. ABP MOC Part 4: 25 points Project: 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
- 77. 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
- 78. 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?
- 79. PICU: 45 beds NICU: 80+ beds CICU: 24 beds Emergency Dept The Children’s Hospital of Philadelphia
- 80. 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
- 81. • 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
Hinweis der Redaktion
- Severe TIAE rate during the same period in PICU was 5.2%, Any minor TIAE rate was 17%, and were not significantly different. However, the Esophageal intuabtion was substantially low, and Mainstem intubation rate was substantially high.
- For successful attempts, &lt;20 seconds, no deterioration, 20-29 seconds, 4/12 deteriotaton (33%), &gt;30sec, 20/27 (75%) deteriorated
- Each encounter can have more than one course. Each course may have multiple attempts. For example, you have a child with bronchiolitis, with desaturation despite the oxygen via face mask. Your team decided to tracheally intubate and provide invasive ventilation. With the standard induction with ketamine and rocuronium, you were able to bag-valve-mask but you could not intubate due to poor visualization even after 2 attempts. You brought a video laryngoscope and you were able to intubate at one attempt with it. We will describe this as 1. Encounter (the patient needing airway management), 2. two courses—there were two approachs, and 3. 2 Attempts belongs to 1st course, and 1 attempt belong to the 2nd course.
- Besides desaturation, we know other unwanted events can occur during intubation. These are called Tracheal Intubation Associated Events also known as TIAEs. Severe TIAEs are listed in red. (15 seconds pause)
- This is how the first year swiss residents learn.
- Overall number of attempts was 38 now 12 over three years in NICU/L and D (UC Davis)
- Data collection from consecutive cardiac arrests of patients greater than 8 yrs of age - implemented in PICU and ED - quantitative CPR quality data and available clinical data (MAP, ETCO2) - 8 events (7 patients, ages 10-22) - continuing staff education with “Rolling Refreshers”
- Data collection from consecutive cardiac arrests of patients greater than 8 yrs of age - implemented in PICU and ED - quantitative CPR quality data and available clinical data (MAP, ETCO2) - 8 events (7 patients, ages 10-22) - continuing staff education with “Rolling Refreshers”
- Data collection from consecutive cardiac arrests of patients greater than 8 yrs of age - implemented in PICU and ED - quantitative CPR quality data and available clinical data (MAP, ETCO2) - 8 events (7 patients, ages 10-22) - continuing staff education with “Rolling Refreshers”
- The safety and quality of tracheal intubation in Pediatric ICU is now being recognized as a significant problem. Next question is how we quantify and measure accurately, and then fix it?
- We created the CVC Dress Rehearsal program using simulation to educate nurses and ensure consistency in practice in changing a central venous catheter dressing.
- This program started as a QI initiative. Once we started to see that we were increasing the knowledge and consistency, we wanted to find out how effective our program really was. In January we began the IR submission process ……… In May 2009, we obtained IRB approval as an exempt study to look at the “effectiveness…
- Our study was a prospective randomized study that took place in all units of the hospital and we recruited nurses from all experience levels to take part in the study
- Our hypothesis was that CVC… And that…
- In our Original Strategy nurses completed the skill one time and their performance was reviewed After 6 months of this strategy we realized it was necessary for nurses to demonstrate this skill 100% correctly or “Train to Excellence” …..so they practiced on the manikin until they could complete the “dress rehearsal” with no corrective prompts. This has become our current practice
- We measured knowledge and confidence using the pre and post training questionnaire that included a likert scale as well as some true and false questions. We measured operational performance on manikins using a skills checklist that is based off the current policy to validate the nurses competence. We record any corrective prompts that are needed during the procedure. We measure operational performance on patients using a direct observation form. This form is completed by a second nurse who observes or assists with the dressing change. As a secondary outcome we measured the incidence rate of CLABSI after initiation of Dress Rehearsals compared to historical control
- We approach a nurse on a given unit and determine if that nurse has a patient with a central line and when that patients central line dressing was due to be changed. We ask the nurse if he or she is able to participate in a CVC dress rehearsal and if they would be willing to participate in our study. If the nurse did not want to participate in the study they were still provided the opportunity to practice the skill. However, we would not use their data. The nurse is then asked to fill out the pre questionnaire and we inform the nurse that we will be using the “train to excellence” approach. The goal is for them to be able to complete the skill 100% correctly so if they make any mistakes, we will have them repeat the entire skill until they get it correct.” These are the supplies that are needed for the CVC Dressing change. We have the nurse complete the skill as they would if they were performing the dressing change for real on their patient and we offer to serve as their assistant After performing hand hygiene and opening the kit, the nurse puts on non sterile procedure gloves Takes off old dressing Uses hand hygiene, puts on sterile gloves and puts out sterile drape The nurse then cleans site for 30 seconds using a chlorhexidine applicator and applies the skin prep barrier And applies the new sterile dressing Upon completion of the simulated dressing change, we review the nurses performance, discuss any corrective prompts that were needed, ask the nurse to repeat the skill if necessary and ask them to complete the post questionnaire
- 525 nurses from units throughout the hospital participated in the dress rehearsals
- Additionally, perception of confidence in their ability to perform the skill increased post dress rehearsal using the Likert scale.
- Knowledge of policy improved post dress rehearsal as evidenced by an increase in the number of correct responses to true/false questions Major improvement was noted in the questions relating to frequency of dressing change, selection of cleansing agent, and need for maximum sterile barriers.
- As compared to the original strategy of completing one “dress rehearsal” and then receiving feedback on performance, when we changed to a “train to excellence” approach where the nurse had to achieve 100% compliance on the manikin without prompting…. Fewer nurses needed prompts during their initial attempt and were able to complete the skill 100% correctly.
- When we changed strategies the types of prompts needed remained the same but the overall number of prompts decreased with the train to excellence strategy.
- Direct observations were collected on 1673 patients. The last question on the direct observation form asked if the nurse had participated in a dress rehearsal with the simulation team. We reviewed these forms and found that nurses who did not do a dress rehearsal required more prompting during the dressing change on their patient.
- The dress rehearsal program was implemented in November 2008,
- As you can see the CLABSI rate dropped after implementation of the dress rehearsals. Mean CLABSI rates/1000 CVC line days Pre dress rehearsals was 5.3 and Post dress rehearsals the rate decreased to a mean of 3.1
- Participation in “Dress Rehearsals” helped eliminate variations in clinical practice Dress Rehearsal participants were more apt to correctly perform a dressing change on a patient “Train to Excellence” strategy appears superior to standard training
- 15 intubations are observed
- This is the plan for the NEAR4KIDS QI project. You are either in a preparation phase, or in the NEAR4KIDS data collection phase if you or your colleagues started the project in your ICU. During the data collection phase for 24 months, we will implement our QI initiatives to improve our measured outcomes. Specifically we aim to reduce our unwanted Tracheal Intubation Associated Events (TIAEs) rate by 30 %.
- Patient care, Practice-based learning & improvement, Interpersonal & communication skills, Professionalism, Systems-based practice
- Although we have written that participants need to be a part of NEAR4Kids for 2 years to get ABP MOC credit you need to be present for 1 year.