University of Arizona
Abstract Authors: Kareem Ahmad, MD; Bhupinder Natt, MD; Joshua Malo, MD; James Knepler, MD; Linda Snyder, MD; Kenneth Knox,MD; Jarrod Mosier, MD
2015 Abstract: http://www.thoracic.org/professionals/career-development/fellows/innovations-in-fellowship-education/2015/ university-of-arizona-medical-center.php
BACKGROUND
Tracheal intubation is a commonly performed, high-risk procedure in the intensive care unit and presents unique challenges for an operator of any skill level. Thus, it is of utmost importance that fellowship programs train the future intensivist to provide optimal airway management. Trainees need to be exposed to and prepared for every scenario, possess the ability to rapidly recognize potential difficulties, and utilize the skill and knowledge to overcome each situation. Previously, we reported our experience with the establishment of an 11-month simulation-based curriculum focusing on providing trainees an easily modifiable and challenging set of scenarios. After 18 months, 16 fellows had completed the curriculum, notably improving our program’s first attempt success (FAS) rates, decreasing complication rates, and raising trainee knowledge, based on objective testing, compared to the 18-month period immediately prior. Now in its third year, the curriculum continues to be the cornerstone of our program’s airway management training. Yet, it has also become a platform for improving patient outcomes and serves as a greater resource for critical care airway management research.
METHODS
We conducted a prospective observational study of patients intubated in our academic medical critical care unit between January 1, 2012 and January 1, 2016. Using a detailed form completed by each operator, we assessed multiple aspects of airway management including: method of intubation, device(s) used, attempts made, operator and patient demographics, difficult airway characteristics, and complications (eg. desaturation > 10%, esophageal intubation, hypotension, etc.). This time period is marked by the initiation of our previously described airway management curriculum in July 2013. Data are reviewed yearly, allowing focused modification of our curriculum and divisional practice patterns.
RESULTS
More than 1200 consecutive intubations occurred over the four-year period. FAS has increased by 30% each year (OR 1.30 per year, 95%CI 1.14- 1.19), as well as the use of video laryngoscopy (VL) (OR= 1.74 per year, 95%CI 1.5-2.03) and the use of neuromuscular blocking agents (NMBA) (OR= 1.25 per year, 95%CI 1.11-1.41). These data show a marked reduction in the use of direct laryngoscopy with over 90% utilization of both VL and NMBA. Also, the most frequent complications noted in our study were desaturation (17%) and hypotension (8.3%). Trainees were further trained in additional pharmacologic interventions, preoxygenation techniques, and optimal patient positioning to reduce the risk of these complications. Over the last four years, the proportion of patients with at least one complication has decreased from 35% to 24%, which has become the major focus of the curriculum for the 2016-2017 academic year. Additionally, we have published several papers on our findings to benefit other providers outside of our institution. As of October 2016, we have produced 10 peer-reviewed publications and presented twenty-nine posters/ oral presentations at national or international meetings, all involving pulmonary and critical care trainees.
CONCLUSION
Our data show that over the four-year period, our airway management curriculum has resulted in a steady increase in the adoption of best practices, increasing first attempt success and reducing procedurally-related complications. In addition, our airway management program also serves as an academically productive resource for involving trainees in quality improvement and clinical research.
