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Advanced Airways Just-in-Time Training

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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.

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Advanced Airways Just-in-Time Training

  1. 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. 2. Disclosure Ongoing support: • Laerdal Foundation Center for Excellence • Endowed Chair Fund, Critical Care Medicine, CHOP Completed support: • AHRQ HS016678-01
  3. 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. 4. Background • ER video clip
  5. 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. 6. Outside view Anatomical view Tracheal Intubation
  7. 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. 8. Age vs. Method Sagarin MJ Pediatric Emergency Care 2002
  9. 9. Condition needing intubation
  10. 10. Adverse Events
  11. 11. • How about the “New 21st Century” with RSI: Rapid Sequence Intubation? Pediatric Airway Management
  12. 12. • A single center study at CHOP from 2006- 2008 • Retrospective chart review including transport team documentation Patients from referral hospitals
  13. 13. Patients needing intubation
  14. 14. Methods • Is sedation + paralytic=RSI: Rapid Sequence Intubation?
  15. 15. Outcomes: TIAEs **
  16. 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. 17. NICU Airway Management Falck et al. Pediatrics 2003
  18. 18. NICU Airway Management Falck et al. Pediatrics 2003
  19. 19. L&D intubations: Video Analysis O’Donnell, et al. Pediatrics 2006
  20. 20. L&D intubations: Video Analysis 30 sec 20 sec O’Donnell, et al. Pediatrics 2006
  21. 21. Airway Management (!?)
  22. 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. 23. NEAR4KIDS project • What is new? -Clear intention to IMPROVE outcomes -Use standardized operational definitions -Structure and clear data points
  24. 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. 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. 26. Outcomes of interest • Process of care: Multiple attempts (> 2 attempts) • Outcomes: Successful airway management or Tracheal Intubation Associated Events (TIAEs)
  27. 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. 28. A single center prospective observational study CHOP PICU for 14 months One encounter in every 2.3 days
  29. 29. Landscape of our practice
  30. 30. Provider and Outcomes
  31. 31. Tracheal Intubation Associated Events (TIAEs) Observed in 20%
  32. 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. 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. 34. Equipment, Medication, Plans Psychomotor and Teamwork Skills Outcome Practice Provider Reasons for Intubation Patient condition Patient
  35. 35. Patient Factors 401 Encounters from CHOP PICUs Nishisaki, et al. Anesthesiology 2009
  36. 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. 37. Technical Skill Training Konrad C et al. Anes Anal 1998;86:635-639
  38. 38. Simulation Study for learning * T1 is longer than the subsequent intubation course
  39. 39. Simulation Study for learning
  40. 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. 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. 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. 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
  44. 44. 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
  45. 45. 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
  46. 46. “Houston, we have a problem!!”
  47. 47. CVC Dress Rehearsal
  48. 48. 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”
  49. 49. • Design: Prospective • Setting: Inpatient units, PACU, OR, Sedation/Radiology, Outpatient Oncology clinic • Population: Nurses with varying levels of experience from above units Methods
  50. 50. 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
  51. 51. Educational Approach
  52. 52. Outcome Measures • Knowledge and confidence – pre/post training questionnaires • Operational performance on manikin – skills checklist • Operational performance on patients – Direct observations • CLABSI incidence rate
  53. 53. Dress Rehearsal
  54. 54. 525 Nurses Participated in CVC Dress Rehearsals
  55. 55. Confidence Improves
  56. 56. True and False Results Knowledge of the Policy Increased after Dress Rehearsal P<0.0001
  57. 57. Corrective Prompts P <0.001
  58. 58. Performance on Manikins Original Train to Excellence
  59. 59. Performance on Patients % of Nurses requiring “prompts” Observations of Dressing Change on 1673 patients P <0.001
  60. 60. CLABSI Rates Decrease! Rates per 1000 Line Days
  61. 61. CLABSI Rates Decrease! After Implementation
  62. 62. 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
  63. 63. • 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
  64. 64. 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
  65. 65. 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%)
  66. 66. 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
  67. 67. Non-trained residents vs. trained residents
  68. 68. Pre-intervention phase vs. Intervention phase
  69. 69. Hot Topic
  70. 70. 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
  71. 71. Encounters per month 050100150 Frequency June 2010 Jan 2011 Encounters per month July 2011
  72. 72. 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%
  73. 73. Benchmarking: Percentage of TIAE Site 01020304050 PercentageofTIAE 1 2 3 4 5 6 7 8 9 10 11 12 13 Mean=23%
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. 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?
  78. 78. PICU: 45 beds NICU: 80+ beds CICU: 24 beds Emergency Dept The Children’s Hospital of Philadelphia
  79. 79. 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
  80. 80. • 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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