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Downes C, Moores C. Anaesthetic management of a neonate with multiple congenital epulides. Anaesth Rep 2023; 11:e12255. [PMID: 37901887 PMCID: PMC10608796 DOI: 10.1002/anr3.12255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 10/31/2023] Open
Abstract
Congenital epulides, rare benign gum tumours which present at birth, pose challenges for neonatal anaesthesia due to potential airway obstruction and surgical requirements. This case report discusses successful anaesthesia for a newborn with these tumours. An oversized facemask enabled an adequate seal, and videolaryngoscopy provided good airway visualisation for orotracheal intubation. Close collaboration between anaesthesia, surgical and nursing teams resulted in safe anaesthesia and surgical removal of the epulides and an uneventful recovery.
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Affiliation(s)
- C. Downes
- Department of AnaestheticsLiverpool Heart and Chest HospitalLiverpoolUK
| | - C. Moores
- Department of AnaestheticsAlder Hey Children's HospitalLiverpoolUK
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Li K, Marsic I, Sarcevic A, Yang S, Sullivan TM, Tempel PE, Milestone ZP, O'Connell KJ, Burd RS. Discovering interpretable medical process models: A case study in trauma resuscitation. J Biomed Inform 2023; 140:104344. [PMID: 36940896 PMCID: PMC10111432 DOI: 10.1016/j.jbi.2023.104344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/20/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
Understanding the actual work (i.e., "work-as-done") rather than theorized work (i.e., "work-as-imagined") during complex medical processes is critical for developing approaches that improve patient outcomes. Although process mining has been used to discover process models from medical activity logs, it often omits critical steps or produces cluttered and unreadable models. In this paper, we introduce a TraceAlignment-based ProcessDiscovery method called TAD Miner to build interpretable process models for complex medical processes. TAD Miner creates simple linear process models using a threshold metric that optimizes the consensus sequence to represent the backbone process, and then identifies both concurrent activities and uncommon-but-critical activities to represent the side branches. TAD Miner also identifies the locations of repeated activities, an essential feature for representing medical treatment steps. We conducted a study using activity logs of 308 pediatric trauma resuscitations to develop and evaluate TAD Miner. TAD Miner was used to discover process models for five resuscitation goals, including establishing intravenous (IV) access, administering non-invasive oxygenation, performing back assessment, administering blood transfusion, and performing intubation. We quantitively evaluated the process models with several complexity and accuracy metrics, and performed qualitative evaluation with four medical experts to assess the accuracy and interpretability of the discovered models. Through these evaluations, we compared the performance of our method to that of two state-of-the-art process discovery algorithms: Inductive Miner and Split Miner. The process models discovered by TAD Miner had lower complexity and better interpretability than the state-of-the-art methods, and the fitness and precision of the models were comparable. We used the TAD process models to identify (1) the errors and (2)the best locations for the tentative steps in knowledge-driven expert models. The knowledge-driven models were revised based on the modifications suggested by the discovered models. The improved modeling using TAD Miner may enhance understanding of complex medical processes.
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Affiliation(s)
- Keyi Li
- Electrical and Computer Engineering Department, Rutgers University, 94 Brett Road, Piscataway, NJ 08854, USA.
| | - Ivan Marsic
- Electrical and Computer Engineering Department, Rutgers University, 94 Brett Road, Piscataway, NJ 08854, USA.
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University 3675 Market Street, Philadelphia, PA 19104, USA.
| | - Sen Yang
- Linkedin, 1000 W Maude Ave, Sunnyvale, CA 94085, USA.
| | - Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Peyton E Tempel
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Karen J O'Connell
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
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Pandian V, Ghazi TU, He MQ, Isak E, Saleem A, Semler LR, Capellari EC, Brenner MJ. Multidisciplinary Difficult Airway Team Characteristics, Airway Securement Success, and Clinical Outcomes: A Systematic Review. Ann Otol Rhinol Laryngol 2022:34894221123124. [DOI: 10.1177/00034894221123124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To investigate whether implementation of a multidisciplinary airway team was associated with improvement in (1) rate of successful airway securement at first attempt; (2) time to secure airway; and (3) overall complication rate in patients with a difficult airway, as compared with usual care. Data Sources: Ovid Medline, Embase, Scopus, Cochrane Central, and CINAHL databases. Review Methods: Systematic review of literature on inpatient multidisciplinary team management of difficult airways, including all studies performed in inpatient settings, excluding studies of ventilator weaning, flight/military medicine, EXIT procedures, and simulation or educational studies. DistillerSR was used for article screening and risk of a bias assessment to evaluate article quality. Data was extracted on study design, airway team composition, patient characteristics, and clinical outcomes including airway securement, complications, and mortality. Results: From 5323 studies screened, 19 studies met inclusion criteria with 4675 patients. Study designs included 12 quality improvement projects, 6 cohort studies, and 1 randomized controlled trial. Four studies evaluated effect of multidisciplinary difficult airway teams on airway securement; all reported higher first attempt success rate with team approach. Three studies reported time to secure the difficult airways, all reporting swifter airway securement with team approach. The most common difficult airway complications were hypoxia, esophageal intubation, hemodynamic instability, and aspiration. Team composition varied, including otolaryngologists, anesthesiologists, intensivists, nurses, and respiratory care practitioners. Conclusion: Multidisciplinary difficult airway teams are associated with improved clinical outcomes compared to unstructured emergency airway management; however, studies have significant heterogeneity in team composition, algorithms for airway securement, and outcomes reported. Further evidence is necessary to define the clinical efficacy, cost-effectiveness, and best practices relating to implementing difficult airway teams in inpatient settings.
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Affiliation(s)
- Vinciya Pandian
- Immersive Learning and Digital Innovations, Nursing Faculty, and Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
| | - Talha U. Ghazi
- Michigan State University College of Human Medicine, West Bloomfield, MI, USA
| | - Marielle Qiaoshu He
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- US Navy Medical Corps, Washington, DC, USA
| | - Ergest Isak
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Abdulmalik Saleem
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Lindsay R. Semler
- INTEGRIS Health, Oklahoma City, OK, USA
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Michael J. Brenner
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
- Global Tracheostomy Collaborative, Raleigh, NC, USA
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Risk factors for inadequate sedation after endotracheal intubation in the pediatric emergency department. Am J Emerg Med 2022; 56:15-20. [DOI: 10.1016/j.ajem.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative. Pediatr Qual Saf 2021; 6:e385. [PMID: 34963998 PMCID: PMC8702256 DOI: 10.1097/pq9.0000000000000385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/18/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative.
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Barnicle R, Bracey A, Zahid B, Davic A, Weingart S. Prioritising intubator safety in a pandemic: the details matter. Emerg Med J 2021; 38:217-219. [PMID: 33402355 DOI: 10.1136/emermed-2020-210362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 12/14/2022]
Abstract
Our ED-intensive care unit has instituted a new protocol meant to maximise the safety of physicians, nurses and respiratory therapists involved with endotracheal intubation of patients known or suspected of being infected with the novel SARS-CoV-2. The level of detail involved with this checklist is a deviation from standard intubation practices and is likely unfamiliar to most emergency physicians. However, the two-person system used in our department removes the cognitive burden such complexity would otherwise demand and minimises the number of participants that would typically be exposed during endotracheal intubation. We share this checklist to demonstrate to other departments how adopting international airway guidelines to a specific institution can be achieved in order to promote healthcare worker safety.
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Affiliation(s)
- Ryan Barnicle
- Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Alexander Bracey
- Emergency Medicine, Albany Medical Center, Albany, New York, USA
| | - Bassam Zahid
- Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Alexandra Davic
- Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Scott Weingart
- Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
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Tippmann S, Haan M, Winter J, Mühler AK, Schmitz K, Schönfeld M, Brado L, Mahmoudpour SH, Mildenberger E, Kidszun A. Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations. Front Pediatr 2021; 9:675238. [PMID: 34046376 PMCID: PMC8144442 DOI: 10.3389/fped.2021.675238] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/16/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Intubation of neonates is difficult and hazardous. Factors associated with procedure-related adverse events and unsuccessful intubation attempts are insufficiently evaluated, especially during neonatal nasotracheal intubations. Objective: Aim of this study was to determine the frequency of tracheal intubation-associated events (TIAEs) during neonatal nasotracheal intubations and to identify factors associated with TIAEs and unsuccessful intubation attempts in our neonatal unit. Methods: This was a prospective, single-site, observational study from May 2017 to November 2019, performed at a tertiary care neonatal intensive care unit in a German academic teaching hospital. All endotracheal intubation encounters performed by the neonatal team were recorded. Results: Two hundred and fifty-eight consecutive intubation encounters in 197 patients were analyzed. One hundred and forty-eight (57.4%) intubation encounters were associated with at least one TIAE. Intubation inexperience (<10 intubation encounters) (OR = 2.15; 95% CI, 1.257-3.685) and equipment problems (OR = 3.43; 95% CI, 1.12-10.52) were predictive of TIAEs. Intubation at first attempt (OR = 0.10; 95% CI, 0.06-0.19) and videolaryngoscopy (OR = 0.47; 96% CI, 0.25-0.860) were predictive of intubation encounters without TIAEs. The first intubation attempt was commonly done by pediatric residents (67.8%). A median of two attempts were performed until successful intubation. Restricted laryngoscopic view (OR = 3.07; 95% CI, 2.08-4.53; Cormack-Lehane grade 2 vs. grade 1), intubation by pediatric residents when compared to neonatologists (OR = 1.74; 95% CI, 1.265-2.41) and support by less experienced neonatal nurses (OR = 1.60; 95% CI, 1.04-2.46) were associated with unsuccessful intubation attempts. Conclusions: In our unit, TIAEs and unsuccessful intubation attempts occurred frequently during neonatal nasotracheal intubations. To improve success rates, quality improvement und further research should target interprofessional education and training, equipment problems and videolaryngoscopy.
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Affiliation(s)
- Susanne Tippmann
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Martin Haan
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Julia Winter
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Ann-Kathrin Mühler
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Katharina Schmitz
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Mascha Schönfeld
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Luise Brado
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Seyed Hamidreza Mahmoudpour
- Division of Medical Biostatistics and Bioinformatics, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - André Kidszun
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Division of Neonatology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Assessment of Nonroutine Events During Intubation After Pediatric Trauma. J Surg Res 2020; 259:276-283. [PMID: 33138986 DOI: 10.1016/j.jss.2020.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intubation in the early postinjury phase can be a high-risk procedure associated with an increased risk of mortality when delayed. Nonroutine events (NREs) are workflow disruptions that can be latent safety threats in high-risk settings and may contribute to adverse outcomes. MATERIALS AND METHODS We reviewed videos of intubations of injured children (age<17 y old) in the emergency department occurring between 2014 and 2018 to identify NREs occurring between the decision to intubate and successful intubation ("critical window"). RESULTS Among 34 children requiring intubation, the indications included GCS≤8 (n = 20, 58.8%), cardiac arrest (n = 6, 17.6%), airway protection (n = 5, 14.7%), and respiratory failure (n = 3, 8.8%). The median duration of the "critical window" was 7.5 min (range 1.4-27.5 min), with a median of six NREs per case in this period (range 2-30). Most NREs (n = 159, 61.9%) delayed workflow, with 31 (12.1%) of these delays each lasting more than one minute. Eighty-seven NREs (33.9%) had a potential for harm but did not lead to direct patient harm. The most common NREs directly related to the intubation process were poor positioning for intubation (n = 23, 8.9%) and difficulty passing the endotracheal tube (n = 5, 1.9%), with most being attributed to the anesthesiologist performing the intubation (n = 51, range 0-7). CONCLUSIONS Workflow disruptions related to nonroutine events were frequent during pediatric trauma intubation and were often associated with delays and potential for patient harm. Interventions for improving the efficiency and timeliness of the critical window should focus on adherence to intubation protocol and improving communication and teamwork related to tasks in this phase.
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Groombridge C, Maini A, Olaussen A, Kim Y, Fitzgerald M, Mitra B, Smit DV. Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis. Emerg Med J 2020; 37:576-580. [PMID: 32554746 DOI: 10.1136/emermed-2019-208935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI. METHODS This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period. RESULTS There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)). CONCLUSIONS This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.
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Affiliation(s)
- Christopher Groombridge
- National Trauma Research Institute, Melbourne, Victoria, Australia .,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia.,Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Amit Maini
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | | | - Yen Kim
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia.,Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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