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Weingart SD, Barnicle RN, Janke A, Bhagwan SD, Tanzi M, McKenna PJ, Bracey A. A taxonomy of key performance errors for emergency intubation. Am J Emerg Med 2023; 73:137-144. [PMID: 37657143 DOI: 10.1016/j.ajem.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/03/2023] Open
Abstract
STUDY OBJECTIVE Currently the videographic review of emergency intubations is an unstructured, qualitative process. We created a taxonomy of errors that impede the optimal procedural performance of emergency intubation. METHODS This was a prospective, observational, study reviewing a convenience sample of deidentified laryngoscopy recordings of emergency department intubations that were qualitatively flagged before the study as demonstrating suboptimal technique. These videos were coded for the presence of 13 predetermined performance errors. Our primary outcome was the incidence of each of these specified errors during emergency intubation. Errors fell into 3 categories: errors of structure recognition during laryngoscope insertion, errors of vallecula manipulation, and errors of device delivery. RESULTS A total of 100 intubation attempts were reviewed. The most common error was inadequate lifting force with the blade tip in the vallecula which lowered the percent of glottic opening, occurring in 45% of the attempts. The least common performance error was the premature removal of the laryngoscope during bougie placement, occurring in only 9% of the videos. CONCLUSION We developed a taxonomy of 13 performance errors of laryngoscopy. Further study is warranted to determine how to best incorporate these into emergency airway training and the airway review process.
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Affiliation(s)
- Scott D Weingart
- Nassau University Medical Center, Department of Emergency Medicine, East Meadow, NY, USA.
| | - Ryan N Barnicle
- Yale New Haven Hospital, Department of Emergency Medicine, New Haven, CT, USA
| | - Alexander Janke
- Yale New Haven Hospital, Department of Emergency Medicine, New Haven, CT, USA
| | - Sabrina D Bhagwan
- Elmhurst Hospital Center, Department of Anesthesia, Elmhurst, NY, USA
| | - Matthew Tanzi
- Stony Brook University Medical Center, Department of Emergency Medicine, Stony Brook, NY, USA
| | - Peter J McKenna
- Stony Brook University Medical Center, Department of Emergency Medicine, Stony Brook, NY, USA
| | - Alexander Bracey
- Albany Medical Center, Department of Emergency Medicine, Albany, NY, USA
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Miller KA, Auerbach M, Bin SS, Donoghue A, Kerrey BT, Mittiga MR, D'Ambrosi G, Monuteaux MC, Marchese A, Nagler J. Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation. AEM EDUCATION AND TRAINING 2023; 7:e10846. [PMID: 36936084 PMCID: PMC10014969 DOI: 10.1002/aet2.10846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 06/18/2023]
Abstract
Background Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Methods Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Results Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. Conclusions This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.
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Affiliation(s)
- Kelsey A. Miller
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Steven S. Bin
- Departments of Pediatrics and Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Aaron Donoghue
- Department of Anesthesiology and Critical CarePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Benjamin T. Kerrey
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | | | | | - Ashley Marchese
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Joshua Nagler
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
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Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand T, Goldman MP, Prieto MM, Wing R, Breuer R, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes. Ann Emerg Med 2023; 81:113-122. [PMID: 36253297 DOI: 10.1016/j.annemergmed.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
| | | | - Andrew F Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Phillip M Thomas
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Tara Neubrand
- Department of Emergency Medicine - Pediatric Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, CT
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, RI
| | - Ryan Breuer
- Department of Pediatrics - Pediatric Critical Care, Oishei Children's Hospital, Buffalo, NY
| | - Jenn D'Mello
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand TL, Goldman MP, Prieto MM, Wing R, Breuer RK, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine. AEM EDUCATION AND TRAINING 2022; 6:e10830. [PMID: 36562026 PMCID: PMC9763969 DOI: 10.1002/aet2.10830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 06/17/2023]
Abstract
Background Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees. Methods This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods. Results There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods. Conclusions The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.
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Affiliation(s)
- Kelsey A. Miller
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Andzelika Dechnik
- Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Andrew F. Miller
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Phillip M. Thomas
- Division of Emergency Medicine, Department of PediatricsCincinnati Children'sCincinnatiOhioUSA
| | - Benjamin T. Kerrey
- Division of Emergency Medicine, Department of PediatricsCincinnati Children'sCincinnatiOhioUSA
| | - Tara Lynn Neubrand
- Department of Pediatrics – Emergency MedicineChildren's Hospital ColoradoAuroraColoradoUSA
| | - Michael Paul Goldman
- Departments of Pediatrics and Emergency MedicineYale‐New Haven Children's HospitalNew HavenConnecticutUSA
| | - Monica M. Prieto
- Department of Pediatrics – Emergency MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Robyn Wing
- Department of Emergency Medicine – Pediatric Emergency MedicineHasbro Children's HospitalProvidenceRhode IslandUSA
| | - Ryan K. Breuer
- Department of Pediatrics – Pediatric Critical CareOishei Children's HospitalBuffaloNew YorkUSA
| | - Jenn D'Mello
- Department of PediatricsUniversity of CalgaryCalgary, AlbertaCaliforniaUnited States
| | - Andy Jakubowicz
- Department of Emergency MedicineWakeMedRaleighNorth CarolinaUSA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
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Abid ES, Miller KA, Monuteaux MC, Nagler J. Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department. Emerg Med J 2021; 39:601-607. [PMID: 34872932 DOI: 10.1136/emermed-2021-211570] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/13/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting. OBJECTIVE We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations. DESIGN AND METHODS We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors. RESULTS During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy. CONCLUSION Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.
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Affiliation(s)
- Edir S Abid
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Lum E, Sommer-Candelario S, Choi SY, Delos Santos S, Aeby K, Lee-Jayaram J. Emergency Pediatric Intubations in an Urban Children’s Hospital Before and After Just-in-Time Training for Video Laryngoscopy. Cureus 2021; 13:e19892. [PMID: 34976504 PMCID: PMC8712208 DOI: 10.7759/cureus.19892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives: The use of video laryngoscopy (VL) may augment emergency pediatric intubations outside the operating room (OR). Our objective was to describe the proportion of use and complications with VL before and after implementation of a VL just-in-time training (JITT). Study design: This study was a retrospective chart review of pediatric intubations performed outside the OR at a single women and children’s hospital from January 2015 to March 2020. Data were collected on patient age, intubation method, operator characteristics, adverse events, number of attempts, condition leading to intubation, and hospital location. Data were separated into pre-JITT (January 1, 2015 to April 31, 2018) and post-JITT (May 1, 2018 to March 1, 2020) periods. Descriptive statistics were used comparing pre- and post-JITT periods for VL use, and the complications of intubations with multiple attempts (IMAs) and intubations with one or more adverse events (AEs). Results: A total of 231 pediatric patients were intubated during the study period; 154 intubations in the pre-JITT and 77 intubations in the post-JITT periods. Pre- and post-JITT VL use was 17 (11%) and 17 (22%), respectively. With pre-JITT VL, there were four (23%) IMAs and zero (0%) intubation with one or more AE. With post-JITT VL, there were eight (47%) IMAs and one (6%) intubation with one or more AE. Conclusion: The proportion of emergency pediatric intubations using VL increased after the institution of a JITT. There was no significant change in IMAs and AEs. The infrequency of pediatric intubations makes drawing conclusions regarding the impact on IMAs and AEs challenging. JITT may increase VL use for emergency pediatric intubations outside the OR and may be considered for refresher training, especially during the coronavirus disease 2019 (COVID-19) pandemic.
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