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

Disclosure

Ongoing support:

• Laerdal Foundation Center for Excellence

• Endowed Chair Fund, Critical Care Medicine, CHOP

Completed support:

• AHRQ HS016678-01

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)

Background

• ER video clip

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

Outside view Anatomical view

Tracheal Intubation

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

Age vs. Method

Sagarin MJ Pediatric Emergency Care 2002

Condition needing intubation

Adverse Events

• How about the “New 21st Century” with RSI: Rapid Sequence Intubation?

Pediatric Airway Management

• A single center study at CHOP from 2006-2008

• Retrospective chart review including transport team documentation

Patients from referral hospitals

Patients needing intubation

Methods

• Is sedation + paralytic=RSI: Rapid Sequence Intubation?

Outcomes: TIAEs

**

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)

NICU Airway Management

Falck et al. Pediatrics 2003

NICU Airway Management

Falck et al. Pediatrics 2003

L&D intubations: Video Analysis

O’Donnell, et al. Pediatrics 2006

L&D intubations: Video Analysis

30 sec

20 sec

O’Donnell, et al. Pediatrics 2006

Airway Management (!?)

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

NEAR4KIDS project

• What is new?

-Clear intention to IMPROVE outcomes

-Use standardized operational definitions

-Structure and clear data points

• 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

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)

Outcomes of interest

• Process of care: Multiple attempts (> 2 attempts)

• Outcomes: Successful airway management or Tracheal Intubation Associated Events (TIAEs)

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

A single center prospective observational studyCHOP PICU for 14 monthsOne encounter in every 2.3 days

Landscape of our practice

Provider and Outcomes

Tracheal Intubation Associated Events (TIAEs)

Observed in 20%

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

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

Equipment, Medication, Plans

Psychomotor and Teamwork Skills

Outcome

PracticeProvider

Reasons for Intubation Patient condition

Patient

Patient Factors

401 Encounters from CHOP PICUs

Nishisaki, et al. Anesthesiology 2009

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

Technical Skill Training

Konrad C et al. Anes Anal 1998;86:635-639

Simulation Study for learning

*

T1 is longer than the subsequent intubation course

Simulation Study for learning

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

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

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

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

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

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

“Houston, we have a problem!!”

CVC　Dress　Rehearsal

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”

• Design: Prospective

• Setting: Inpatient units, PACU, OR, Sedation/Radiology, Outpatient Oncology clinic

• Population: Nurses with varying levels of experience from above units

Methods

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

Educational　Approach

　Outcome　Measures

• Knowledge and confidence– pre/post training questionnaires

• Operational performance on manikin– skills checklist

• Operational performance on patients – Direct observations

• CLABSI incidence rate

Dress　Rehearsal

525 Nurses Participated in CVC Dress Rehearsals

Confidence　Improves

True　and　False　Results

Knowledge of the Policy Increased after Dress Rehearsal

P<0.0001

Corrective　Prompts

P <0.001

Performance　on　Manikins

Original Train to Excellence

Performance　on　Patients

% of Nurses requiring “prompts”

Observations of Dressing Change on 1673 patients P <0.001

CLABSI　Rates　Decrease!

Rates per 1000 Line Days

CLABSI　Rates　Decrease!

AfterImplementation

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

• 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

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

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%)

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

Non-trained residents vs. trained residents

Pre-intervention phase vs. Intervention phase

Hot Topic

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

Encounters per month0

5010

015

0F

req

uen

cy

June 2010 Jan 2011

Encounters per month

July 2011

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%

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%

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

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

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

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?

PICU: 45 beds

NICU: 80+ beds

CICU: 24 beds

Emergency Dept

The Children’s Hospital of Philadelphia

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

• 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