UC Davis Health System
Sacramento, CA

Program Director: Brian Morrissey, MD

Program Associate Director: Nicholas Stollenwer, MD

Program Type: Pulmonary/Critical Care

Abstract Authors: Bradley Tokeshi, MD Eduardo Solbes, MD Nicholas Stollenwerk, MD

Description of Fellowship Program: We are an accredited program in Pulmonary and Critical Care medicine in Sacramento. 

Abstract

Background

The ICU is a high-intensity and oftentimes chaotic setting where time critical decision-making, clear interpersonal communication, and leadership are crucial attributes that should be deliberately forged during a critical care fellowship.  While some trainees have had lectures on leadership in residency or medical school, more often then not we have been forced to haphazardly emulate leadership qualities in our most respected attending physicians in lieu of a formal training program.  The use of Crew Resource Management (CRM) has been described in the critical care literature and was initially developed in the 1970’s by the aviation industry in order to decrease human error by facilitating team-work and leadership.  Our goal was to develop first year PCCM fellow leadership skills using the CRM model and advanced airway management as a critical care scenario.

Methods

 In this ongoing study we plan on a two phase approach.  During our first phase, a CRM training program was introduced to all of our first year pulmonary critical care fellows during their orientation month July 2017.  While teaching basic airway management we also emphasized the following: situational awareness, effective use of our airway checklist, verbally stating an airway plan out loud to the team, rapidly adapting to a developing situation, identification of team roles, and promotion of effective closed-loop communication.  Following a formal lecture period, trainees were then introduced to a high-fidelity simulation session in order to reinforce technical and team management skills.  We administered a pre and post-test survey to assess the fellows’ comfort level in airway team management.  After an intensive 16 week clinical rotation, it is expected that our first year fellows have gained some real-world experience and facility with the technical aspects of intubation and basic airway management.  Our second session, which is scheduled for November 2017, will demonstrate advanced airway techniques and reinforce CRM techniques.  The second course will combine instruction in advanced airway management techniques with a graded assessment of the fellows’ ability to function as an airway manager utilizing a leadership assessment tool that we developed.  Grading will be performed by a volunteer critical care nurse and senior pulmonary and critical care fellow who is not involved in course design or instruction. Real-time feedback will then be given to the fellow.

Results

For the first session, a pre- and post-course survey was used to assess fellows’ comfort in serving as an airway manager and directing personnel during an intubation procedure on a scale of 1 to 5 (1=not comfortable, 5=very comfortable). The mean pre-course score was 2.25, standard deviation (SD) 1.50, and the mean post-course score was 3.25, SD 0.50. The difference of means was 1 [95% CI 0.93-2.93, 2-sided p=0.23].  The results from the second session will be reported upon completion of the course.

Discussion

The successful management of a patient’s airway is seldom achieved by one individual. As with many high-stakes interventions, effective coordination of several simultaneous actions by a team leader in concert with team members is required to obtain the desired outcome. While airway management courses often focus on the technical aspects of securing a patient’s airway, we feel that this approach, while necessary, is not sufficient. We feel a crucial aspect of fellow education in performing high-stakes critical care procedures such as airway management is the ability to function as an effective team leader. Our study will continue to evaluate the efficacy of high-fidelity simulation combined with real-time feedback using an objective assessment tool in developing not just competent airway managers, but future team-leaders in the ICU.