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Boyd S, Murphy CJ, Snyman L. Single-use vs. reusable flexible bronchoscopes for airway management and in critical care: a narrative review. Anaesthesia 2025; 80:197-204. [PMID: 39344667 PMCID: PMC11726266 DOI: 10.1111/anae.16430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION Flexible bronchoscopes have become essential in the operating theatre environment and in critical care. This narrative review compared single-use and reusable flexible bronchoscopes with a focus on safety, efficacy, cost-effectiveness and environmental impact. METHODS We searched MEDLINE, Embase and PubMed databases for studies related to flexible bronchoscopes for airway management or use in critical care. Human or animal studies of any design assessing single-use and reusable flexible bronchoscopes were included and qualitatively synthesised. We also searched manufacturer websites for relevant data. RESULTS We included 52 studies and data from six manufacturer websites. There was mixed evidence for safety, and data on usability also showed significant heterogeneity, with different parameters, manufacturers and models examined. Neither single-use nor reusable flexible bronchoscopes appeared convincingly superior to the other for safety or usability. Cost analyses showed that the rate of use of flexible bronchoscopes per year, along with several other factors, affects cost-effectiveness for each institution, though the risk of cross-contamination is an advantage of single-use devices. However, sufficient evidence on the rate of bronchoscopy-induced infection in the operating theatre and critical care environment is lacking. Due to the risk of cross-contamination, single-use flexible bronchoscopes must be sterilised or incinerated after use, and completely recyclable single-use models are not currently available. CONCLUSIONS Further research is required on safety, usability and life cycle assessment in the operating theatre and critical care environment, as well as on the rate of bronchoscopy-induced infection. Future comparative studies, including new manufacturers and designs, may lend further insights.
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Affiliation(s)
- Sean Boyd
- Department of AnaesthesiologyTallaght University HospitalTallaghtDublinIreland
| | - Ciara J. Murphy
- Department of AnaesthesiologyTallaght University HospitalTallaghtDublinIreland
| | - Lindi Snyman
- Department of AnaesthesiologyTallaght University HospitalTallaghtDublinIreland
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Endlich Y, Davies EL, Kelly J. The nature of the response to airway management incident reports in high income countries: A scoping review. Anaesth Intensive Care 2024; 52:283-301. [PMID: 39219018 DOI: 10.1177/0310057x241227238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.
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Affiliation(s)
- Yasmin Endlich
- School of Medicine, The University of Adelaide, Adelaide, Australia
- School of Nursing, The University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Department of Anaesthesia, Adelaide, Australia
| | - Ellen L Davies
- Adelaide Health Simulation, The University of Adelaide, Adelaide, Australia
| | - Janet Kelly
- School of Nursing, The University of Adelaide, Adelaide, Australia
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Wing R, Goldman MP, Prieto MM, Miller KA, Baluyot M, Tay KY, Bharath A, Patel D, Greenwald E, Larsen EP, Polikoff LA, Kerrey BT, Nishisaki A, Nagler J. Usability Testing Via Simulation: Optimizing the NEAR4PEM Preintubation Checklist With a Human Factors Approach. Pediatr Emerg Care 2024; 40:575-581. [PMID: 39078284 DOI: 10.1097/pec.0000000000003223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
OBJECTIVES To inform development of a preintubation checklist for pediatric emergency departments via multicenter usability testing of a prototype checklist. METHODS This was a prospective, mixed methods study across 7 sites in the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) collaborative. Pediatric emergency medicine attending physicians and senior fellows at each site were first oriented to a checklist prototype, including content previously identified using a modified Delphi approach. Each site used the checklist in 2 simulated cases: an "easy airway" and a "difficult airway" scenario. Facilitators recorded verbalization, completion, and timing of checklist items. After each simulation, participants completed an anonymous usability survey. Structured debriefings were used to gather additional feedback on checklist usability. Comments from the surveys and debriefing were qualitatively analyzed using a framework approach. Responses informed human factors-based optimization of the checklist. RESULTS Fifty-five pediatric emergency medicine physicians/fellows (4-13 per site) participated. Participants found the prototype checklist to be helpful, easy to use, clear, and of appropriate length. During the simulations, 93% of checklist items were verbalized and more than 80% were completed. Median time to checklist completion was 6.2 minutes (interquartile range, 4.8-7.1) for the first scenario and 4.2 minutes (interquartile range, 2.7-5.8) for the second. Survey and debriefing data identified the following strengths: facilitating a shared mental model, cognitively offloading the team leader, and prompting contingency planning. Suggestions for checklist improvement included clarifying specific items, providing more detailed prompts, and allowing institution-specific customization. Integration of these data with human factors heuristic inspection resulted in a final checklist. CONCLUSIONS Simulation-based, human factors usability testing of the National Emergency Airway Registry for Pediatric Emergency Medicine Preintubation Checklist allowed optimization prior to clinical implementation. Next steps involve integration into real-world settings utilizing rigorous implementation science strategies, with concurrent evaluation of the impact on patient outcomes and safety.
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Affiliation(s)
- Robyn Wing
- From the Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital; Lifespan Medical Simulation Center, Providence, RI
| | - Michael P Goldman
- Departments of Pediatrics (Section of Pediatric Emergency Medicine) and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Monica M Prieto
- Perelman School of Medicine at the University of Pennsylvania, Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kelsey A Miller
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Division of Pediatric Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Mariju Baluyot
- Departments of Pediatrics and Emergency Medicine, Indiana University School of Medicine, Divisions of Pediatric Emergency Medicine and Simulation, Riley Hospital for Children, Indianapolis, IN
| | - Khoon-Yen Tay
- Perelman School of Medicine at the University of Pennsylvania, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anita Bharath
- Department of Emergency Medicine, Phoenix Children's, Phoenix, AZ
| | - Deepa Patel
- Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Division of Pediatric Emergency Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Emily Greenwald
- Department of Pediatrics, Duke Children's Hospital, Duke University Hospital, Durham, NC
| | - Ethan P Larsen
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lee A Polikoff
- Division of Critical Care Medicine, Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Benjamin T Kerrey
- University of Cincinnati, College of Medicine and the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Akira Nishisaki
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Joshua Nagler
- Departments of Emergency Medicine and Pediatrics, Harvard Medical School, Division of Pediatric Emergency Medicine, Boston Children's Hospital, Boston, MA
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4
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Davis DP, Chandran K, Noce J. A Descriptive Analysis of Air Medical Pediatric Rapid Sequence Intubation: Successes and Opportunities. Air Med J 2024; 43:210-215. [PMID: 38821700 DOI: 10.1016/j.amj.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement. METHODS All pediatric patients (age < 18 years) undergoing RSI by air medical crews between 2015 and 2019 were included in this analysis. Subjects were divided a priori into 3 age subgroups (0-2 years, 3-8 years, and 9-17 years). The primary variables of interest included overall intubation success, first-attempt intubation success, and first-attempt intubation success without desaturation. The rates of positive-pressure ventilation (PPV) use for preoxygenation and oxygen desaturation were also explored. RESULTS A total of 1,091 pediatric RSI patients were included. The overall intubation success rate was 98% (0-2 years = 96%, 3-8 years = 97%, and 9-17 years = 98%), with 91% intubated on the first attempt (0-2 years = 86%, 3-8 years = 90%, and 9-17 years = 92%) and 87% intubated on the first attempt without oxygen desaturation (0-2 years = 80%, 3-8 years = 88%, and 9-17 years = 90%). A sharp decline in intubation success was observed with preoxygenation SpO2 values < 97% across all patients. Younger patients (0-2 years) had lower initial SpO2 values and decreased first-attempt success rates with and without desaturation. These patients were less likely to receive PPV during preoxygenation attempts and had lower use of video laryngoscopy or a bougie on the initial intubation attempt. CONCLUSION In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO2 values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.
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Affiliation(s)
- Daniel P Davis
- Logan Health, Division of EMS, Kalispell, MT; Air Methods Corporation, Greenwood Village, CO.
| | - Kira Chandran
- Georgetown School of Medicine, Georgetown, Washington DC; Harvard Affiliated Emergency Medicine Program, Boston, MA
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Lima LC, Cumino DDO, Vieira AM, Silva CHRD, Neville MFL, Marques FO, Quintão VC, Carlos RV, Fujita ACG, Barros HÍM, Garcia DB, Ferreira CBT, Barros GAMD, Módolo NSP. Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744478. [PMID: 38147975 PMCID: PMC10877349 DOI: 10.1016/j.bjane.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.
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Affiliation(s)
- Luciana Cavalcanti Lima
- Instituto Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil; Faculdade Pernambucana de Saúde, Recife, PE, Brazil
| | - Débora de Oliveira Cumino
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | | | | | - Mariana Fontes Lima Neville
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, Disciplina de Anestesiologia, Dor e Terapia Intensiva, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil
| | | | - Vinicius Caldeira Quintão
- Universidade de São Paulo, Faculdade de Medicina, Disciplina de Anestesiologia, São Paulo, SP, Brazil
| | - Ricardo Vieira Carlos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Ana Carla Giosa Fujita
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | - Hugo Ítalo Melo Barros
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | | | | | - Guilherme Antonio Moreira de Barros
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil.
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Abstract
Safe and effective management of the neonatal airway requires knowledge, teamwork, preparation and experience. At baseline, the neonatal airway can present significant challenges to experienced neonatologists and paediatric anaesthesiologists, and increased difficulty can be due to anatomical abnormalities, physiological instability or increased situational stress. Neonatal airway obstruction is under recognised, and should be considered an emergency until the diagnosis and physiological implications are understood. When multiple types of difficulties are present or there are multiple levels of anatomical obstruction, the challenge increases exponentially. In these situations, preparation, multi-disciplinary teamwork and a consistent hospital-wide approach will help to reduce errors and morbidity.
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Affiliation(s)
- Toby Kane
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Department of Neonatology, Royal Children's Hospital, Parkville, Australia.
| | - Anastasia Pellicano
- Department of Neonatology, Royal Children's Hospital, Parkville, Australia; Paediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Parkville, Australia
| | - Stefano Sabato
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Australia; Anaesthetics, Murdoch Children's Research Institute, Parkville, Australia
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7
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Fleishhacker ZJ, Bennion DM, Manaligod J, Kacmarynski D, Ropp BY, Kanotra S. Quality Improvement of Pediatric Airway Emergency Carts: Standardization, Streamlining, and Simulation. Cureus 2023; 15:e39727. [PMID: 37398737 PMCID: PMC10310310 DOI: 10.7759/cureus.39727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Objective Pediatric airway emergencies are amongst the most tenuous scenarios faced by on-call providers, requiring quick access to the appropriate equipment and a timely response. In the present study, we report on the testing and improvement of pediatric airway carts at our institution. The primary objective was to optimize our pediatric airway emergency carts to improve response times. Secondarily, we aimed to implement a training scenario to improve providers' familiarity and confidence in attaining and assembling equipment. Methods Surveys of airway cart configuration at our hospital and others were used to identify differences. Volunteer otolaryngology physicians were tasked with responding to a mock scenario using an existing cart or one modified based on the survey. Outcomes included (1) time to arrival of the provider with the appropriate equipment, (2) time from arrival to complete assembly of equipment, and (3) time for re-assembly of the equipment. Results The survey revealed differences in cart equipment and location. The inclusion of a flexible bronchoscope and a video tower, as well as the placement of the carts directly within the ICU, resulted in improved time to arrival by an average of 181 seconds, and improved equipment assembly time by an average of 85 seconds. Discussion Standardization of pediatric airway equipment on the cart and location near critically ill patients improved response efficiency. Simulation led to improved confidence and reduced reaction time among providers at all levels of experience. Conclusion The present study provides an example for the optimization of airway carts, which can be adapted by healthcare systems to their local milieu.
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Affiliation(s)
- Zachary J Fleishhacker
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Douglas M Bennion
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Jose Manaligod
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Deborah Kacmarynski
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Bonita Y Ropp
- Nursing, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Sohit Kanotra
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
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8
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Miller KA, Prieto MM, Wing R, Goldman MP, Polikoff LA, Nishisaki A, Nagler J. Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach. Emerg Med J 2023; 40:287-292. [PMID: 36788006 DOI: 10.1136/emermed-2022-212758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 02/03/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Airway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED is lacking. METHODS A multidisciplinary panel of 14 experts in airway management within and outside of paediatric emergency medicine participated in a modified Delphi approach to develop consensus on the appropriate components for a paediatric airway management checklist for the ED. Panel members reviewed, modified and added to the components from the National Emergency Airway Registry for Children airway safety checklist for paediatric intensive care units using a 9-point appropriateness scale. Components with a median score of 7.0-9.0 and a 25th percentile score ≥7.0 achieved consensus for inclusion. A priori, the modified Delphi method was limited to a maximum of two rounds for consensus on essential components and one additional round for checklist creation. RESULTS All experts participated in both rounds. Consensus was achieved on 22 components. Twelve were original candidate items and 10 were newly suggested or modified items. Consensus components included the following categories: patient assessment and plan (5 items), patient preparation (5 items), pharmacy (2 items), equipment (7 items) and personnel (3 items). The components were formatted into a 17-item clinically usable checklist. CONCLUSIONS Using the modified Delphi method, consensus was established among airway management experts around essential components for an airway management checklist intended for paediatric tracheal intubation in the ED.
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Affiliation(s)
- Kelsey A Miller
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, Connecticut, USA
| | - Lee A Polikoff
- Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua Nagler
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Schmucker Agudelo E, Farré Pinilla M, Andreu Riobello E, Franco Castanys T, Villaverde Castillo I, Monclus Diaz E, Aragonés Panadés N, Muñoz Luz A. An update in paediatric airway management. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:472-486. [PMID: 36096882 DOI: 10.1016/j.redare.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 05/25/2021] [Indexed: 06/15/2023]
Affiliation(s)
- E Schmucker Agudelo
- Hospital Universitario Vall d'Hebrón, Área Materno Infantil, Barcelona, Spain.
| | | | - E Andreu Riobello
- Hospital Universitario Vall d'Hebrón, Área Materno Infantil, Barcelona, Spain
| | | | | | | | | | - A Muñoz Luz
- Hospital Universitario Dr. Josep Trueta, Girona, Spain
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Whytock CW, Atkinson MS. Increasing use of an endotracheal intubation safety checklist in the emergency department. BMJ Open Qual 2021; 10:e001575. [PMID: 34887300 PMCID: PMC8663106 DOI: 10.1136/bmjoq-2021-001575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/22/2021] [Indexed: 01/04/2023] Open
Abstract
Endotracheal intubation (ETI) is a high-risk procedure often performed in the emergency department (ED) in critically unwell patients. The fourth National Audit Project by The Royal College of Anaesthetists found the risk of adverse events is much higher when performing the intervention in this setting compared with a theatre suite, and therefore use of a safety checklist is recommended. This quality improvement project was set in a large teaching hospital in the North West of the UK, where anaesthesia and intensive care clinicians are responsible for performing this procedure. A retrospective baseline audit indicated checklist use was 16.7% of applicable cases. The project aim was to increase the incidence of checklist use in the ED to 90% within a 6-month period. The model for improvement was used as a methodological approach to the problem along with other quality improvement tools, including a driver diagram to generate change ideas. The interventions were targeted at three broad areas: awareness of the checklist and expectation of use, building a favourable view of the benefits of the checklist and increasing the likelihood it would be remembered to use the checklist in the correct moment. After implementation checklist use increased to 84%. In addition, run chart analysis indicated a pattern of nonrandom variation in the form of a shift. This coincided with the period shortly after the beginning of the interventions. The changes were viewed favourably by junior and senior anaesthetists, as well as operating department practitioners and ED staff. Limitations of the project were that some suitable cases were likely missed due to the method of capture and lack of anonymous qualitative feedback on the changes made. Overall, however, it was shown the combination of low-cost interventions made was effective in increasing checklist use when performing emergency ETI in the ED.
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Grissom TE, Samet RE. The Anesthesiologist's Role in Teaching Airway Management to Nonanesthesiologists: Who, Where, and How. Adv Anesth 2021; 38:131-156. [PMID: 34106831 PMCID: PMC7534755 DOI: 10.1016/j.aan.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA
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12
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Optimizing Rapid Sequence Intubation for Medical and Trauma Patients in the Pediatric Emergency Department. Pediatr Qual Saf 2020; 5:e353. [PMID: 33062904 PMCID: PMC7523837 DOI: 10.1097/pq9.0000000000000353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/23/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Rapid sequence intubation (RSI) is a critical procedure for severely ill and injured patients presenting to the pediatric emergency department (PED). This procedure has a high risk of complications, and multiple attempts increase this risk. We aimed to increase successful intubation within two attempts, focusing on medical and trauma patients separately to identify improvement barriers for each group. Methods A multifaceted intervention was implemented using quality improvement methods. The analysis included adherence to the standardized process, successful intubation within two attempts, and frequency of oxygen saturations <92% during laryngoscopy. Trauma and medical patients were analyzed separately as team composition differed for each. Results This project began in February 2018, and we included 290 patients between April 2018 and December 2019. Adherence to the standardized process was sustained at 91% for medical patients and a baseline of 55% for trauma patients with a trend toward improvement. In May 2018, we observed and sustained special cause variations for medical patients' successful intubations within two attempts (77-89%). In September 2018, special cause variation was observed and sustained for the successful intubation of trauma patients within two attempts (89-96%). The frequency of oxygen saturation of <92% was 21% for medical patients; only one trauma patient experienced oxygen desaturation. Conclusion Implementation of a standardized process significantly improved successful intubations within two attempts for medical and trauma patients. Trauma teams had more gradual adherence to the standardized process, which may be related to the relative infrequency of intubations and variable team composition.
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Abstract
OBJECTIVE This study aimed to organize the literature on cognitive aids to allow comparison of findings across studies and link the applied work of aid development to psychological constructs and theories of cognition. BACKGROUND Numerous taxonomies have been developed, all of which label cognitive aids via their surface characteristics. This complicates integration of the literature, as a type of aid, such as a checklist, can provide many different forms of support (cf. prospective memory for steps and decision support for alternative diagnoses). METHOD In this synthesis of the literature, we address the disparate findings and organize them at their most basic level: Which cognitive processes does the aid need to support? Which processes do they support? Such processes include attention, perception, decision making, memory, and declarative knowledge. RESULTS Cognitive aids can be classified into the processes they support. Some studies focused on how an aid supports the cognitive processes demanded by the task (aid function). Other studies focused on supporting the processes needed to utilize the aid (aid usability). CONCLUSION Classifying cognitive aids according to the processes they support allows comparison across studies in the literature and a formalized way of planning the design of new cognitive aids. Once the literature is organized, theory-based guidelines and applied examples can be used by cognitive aid researchers and designers. APPLICATION Aids can be designed according to the cognitive processes they need to support. Designers can be clear about their focus, either examining how to support specific cognitive processes or improving the usability of the aid.
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Long E, Barrett MJ, Peters C, Sabato S, Lockie F. Emergency intubation of children outside of the operating room. Paediatr Anaesth 2020; 30:319-330. [PMID: 31834647 DOI: 10.1111/pan.13784] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 12/19/2022]
Abstract
Intubation of children outside of the operating room is performed infrequently and is often associated with life-threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non-operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems-based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi-disciplinary team training in the technical and nontechnical aspects of non-operating room intubation, debrief post-real and simulated events, and regular audit of performance all reduce life-threatening intubation-related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient-centered care delivery.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Vic., Australia
| | - Michael J Barrett
- Department of Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Cheryl Peters
- Pediatric Anesthesiology and Intensive Care, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Stefan Sabato
- Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Vic., Australia
| | - Francis Lockie
- Paediatric Emergency Department, Womens and Childrens Hospital, Adelaide, SA, Australia.,South Australia Ambulance Service MedSTAR Kids Emergency Retrieval, Adelaide, SA, Australia
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15
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Ghedina N, Alkhouri H, Badge H, Fogg T, McCarthy S. Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR. Emerg Med Australas 2019; 32:401-408. [DOI: 10.1111/1742-6723.13416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Nicole Ghedina
- Emergency DepartmentSt John of God Midland Public Hospital Perth Western Australia Australia
- Royal Flying Doctor Service Western Operations Perth Western Australia Australia
| | - Hatem Alkhouri
- Agency for Clinical InnovationEmergency Care Institute Sydney New South Wales Australia
- Faculty of MedicineThe University of New South Wales Sydney New South Wales Australia
| | - Helen Badge
- Agency for Clinical InnovationEmergency Care Institute Sydney New South Wales Australia
- Faculty of MedicineThe University of New South Wales Sydney New South Wales Australia
| | - Toby Fogg
- Emergency DepartmentRoyal North Shore Hospital Sydney New South Wales Australia
- CareFlight/NSW Ambulance Service Sydney New South Wales Australia
| | - Sally McCarthy
- Emergency DepartmentPrince of Wales Hospital Sydney New South Wales Australia
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16
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Sanders R, Edwards L, Nishisaki A. Tracheal Intubations for Critically Ill Children Outside Specialized Centers in the United Kingdom-Patient, Provider, Practice Factors, and Adverse Events. Pediatr Crit Care Med 2019; 20:572-573. [PMID: 31162351 PMCID: PMC6550333 DOI: 10.1097/pcc.0000000000001946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ron Sanders
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
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17
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Teo SSS, Rao A, Acworth J. Paediatric acute care: Highlights from the Paediatric Acute Care-Advanced Paediatric Life Support Conference, Gold Coast, 2017. Emerg Med Australas 2018; 30:581-584. [DOI: 10.1111/1742-6723.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 03/25/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Stephen SS Teo
- Paediatric and Emergency Departments; Blacktown and Mt Druitt Hospitals; Sydney New South Wales Australia
- Paediatric Department, School of Medicine; Western Sydney University; Sydney New South Wales Australia
| | - Arjun Rao
- Emergency Department; Sydney Children's Hospital; Sydney New South Wales Australia
| | - Jason Acworth
- Emergency Department; Lady Cilento Children's Hospital; Brisbane Queensland Australia
- Faculty of Medicine; The University of Queensland; Brisbane Queensland Australia
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18
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Long E, Cincotta DR, Grindlay J, Sabato S, Fauteux-Lamarre E, Beckerman D, Carroll T, Quinn N. A quality improvement initiative to increase the safety of pediatric emergency airway management. Paediatr Anaesth 2017; 27:1271-1277. [PMID: 29063722 DOI: 10.1111/pan.13275] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Emergency airway management is commonly associated with life-threatening hypoxia and hypotension which may be preventable. AIMS The aim of this quality improvement study was to reduce the frequency of intubation-related hypoxia and hypotension. METHODS This prospective quality improvement study was conducted over 4 years in the Emergency Department of The Royal Children's Hospital, Melbourne, Australia. A preintervention cohort highlighted safety gaps and was used to design study interventions, including an emergency airway algorithm, standardized airway equipment, a preintubation checklist and equipment template, endtidal carbon dioxide monitoring, postintubation team debriefing, and multidisciplinary team training. Following implementation, a postintervention cohort was used to monitor the impact of study interventions on clinical process and patient outcome. Process measures were as follows: use of a preintubation checklist, verbalization of an airway plan, adequate resuscitation prior to intubation, induction agent dose titration, use of apneic oxygenation, and use of endtidal carbon dioxide to confirm endotracheal tube position. The primary outcome measure was first pass success rate without hypoxia or hypotension. Potential harms from study interventions were monitored. RESULTS Forty-six intubations were included over one calendar year in the postintervention cohort (compared to 71 in the preintervention cohort). Overall clinical uptake of the 6 processes measures was 85%. First pass success rate without hypoxia or hypotension was 78% in the postintervention cohort compared with 49% in the preintervention cohort (absolute risk reduction: 29.0%; 95% confidence interval 12.3%-45.6%, number needed to treat: 3.5). No significant harms from study interventions were identified. CONCLUSION Quality improvement initiatives targeting emergency airway management may be successfully implemented in the emergency department and are associated with a reduction in adverse intubation-related events.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia
| | - Domenic R Cincotta
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia
| | - Joanne Grindlay
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia
| | - Stefano Sabato
- Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Vic., Australia
| | - Emmanuelle Fauteux-Lamarre
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia
| | - David Beckerman
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Department of Nursing, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia
| | - Terry Carroll
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Vic., Australia.,Department of Nursing, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia
| | - Nuala Quinn
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia
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