Combined Team Function: Critical Care Airway Management

1. Combined Team Function: Critical Care Airway Management Paul H. Mayo M.D. Director MICU NSLIJ Professor of Clinical Medicine Hofstra NSLIJ School of Medicine (No disclosures)

2. A Word About OR Endotracheal Intubation • Very well studied • Very low rate of complication • Very high rate of success

3. Why? • Perfect operational environment • Optimal patient physiology • Full airway evaluation and preparation • Elective advanced airway methods • Wake-up/back out option available • Highly skilled intubators • Awake FOB option

4. Emergency Endotracheal Intubation (EEI) • Any endotracheal intubation that does not occur in the operating room • Venues: ICU, wards, ED • Providers at in USA include critical care staff, anesthesiologists (attending and NP), and EM staff • Often occurs in the context of training house staff

5. What About EEI? • Poor operational environment • Highly abnormal patient physiology • Difficulty in airway evaluation • No time to anticipate or prepare • No wake-up and back-out option • Personnel may be in training

6. How Dangerous is EEI? • Four large studies describing EEI performed by anesthesiologists • Mortality 2% • Serious complication: 25% (profound hypotension/desaturation) • Esophageal intubation: 10% • EEI: the most dangerous critical care procedure

7. Severe hypotension 25% Jaber S, Crit Care Med 2006

8. Problems with EEI • EEI is required in critically ill patients who have limited physiological reserve • They are hemodynamically unstable or…. • They have respiratory failure or…, • They have both

9. Death and Brain Injury • Related to underlying illness and the need to use sedating agents for EEI, patients are at very high risk for hypoxemia and/or hypotension • Hypoxemia and/or hypotension result in brain injury and if prolonged….death

10. A Quiet Epidemic • Even brief periods of hypotension and/or hypoxemia may cause brain injury • Many patients recover from critical illness but have permanent brain injury • I believe that many of these cases derive from problems related to EEI that are not documented

11. The Sad Truth • The intubation sequence frequently results in significant desaturation and hypotension • The patient survives the critical illness but has suffered brain injury • There is no back-up plan • They (and we) engage in selective memory, white washing, and “it’s the patients fault” defense

12. Some Disturbing Facts • The 80/80 rule: anesthesia residents are successful 80% of the time on the 80th case….for routine OR intubation • The learning curve flattens out at between 500 to 1000 for OR EI • EEI is much more difficult than routine OR EI • How many EEI have you performed?

13. Why Does EEI Go Wrong? • The lone ranger syndrome • Blame the patient • The under the radar effect • Lack of hard endpoints: Saturation, BP, attempts, failures, complications • Lack of transparency in documentation • Clinical chaos, CMA, lack of team effort, emotional issues, low frequency effect

14. The Plight of the Anesthesiologist • Unfamiliar operating environment • Unfamiliar personnel • Lack of back-up personnel • Lack of back-up plan • Abrupt extreme clinical pressure

15. The Plight of the Intensivist • Unstable patient with high risk airway • Low frequency/high risk event • Abrupt extreme clinical pressure • Obligation to train inexperienced personnel in the most dangerous procedure of critical medicine • Often in USA….non-expert level intubating skills

16. Should EEI Be Entirely Under Anesthesiology Control? • Repeated examples of profound failure of EEI when Anesthesiology was in primary control • A need to train fellows • A perception that careful CQI analysis might improve EEI sequence

17. The Challenge • How to intubate the critically ill patient safely in a training environment • Simple goals: SaO2>90%, systolic BP> 100 systolic, stable cardiac rhythm, and successful ET intubation performed by the trainee • Alternative: Call for anesthesiology as primary or immediate back-up intubator

18. Improve the Process • Define the process in segmental detail • Identify points of improvement • Improve those that are most likely to yield greatest benefit…. “low hanging fruit” • Always measure effect, and proceed with continuous segmental process improvement

19. The Very Low Hanging Fruit • The best way to avoid desaturation is to have a well saturated patient • We observed terrible bag mask ventilation (BVM) technique during EEI • Solution: train an army of BVM experts • Who to train: an army of medical interns • How to train: scenario based training with a computerized patient simulator (SBT with CPS)

20. Other Low Hanging Fruit • High risk low frequency events require team work; this requires a team leader • We observed poor team function and absence of team leadership • Solution: train team leaders • Who: PCCM fellows • How: SBT with CPS

21. Other Low Hanging Fruit • A complex process should be done in a standardized manner • We observed marked variation in set up • Solution: develop a standard approach • Who: PCCM faculty and fellows • How: read, discuss, review clinical events….constantly rethink and refine

22. Other Low Hanging Fruit • Only qualified clinicians should perform a difficult procedure • Solution: only qualified clinicians should perform the act of intubation • Other team members perform critical tasks for which they are trained

23. Other Low Hanging Fruit • EEI set up requires a well planned bailout plan • Solution: develop a plan and acquire the equipment

24. High Hanging Fruit • How to find it? • Detailed debriefing following EEI • Solution: improve process by identifying failure points

25. Examples • Addition of PEEP valve to BVM • Careful briefing of medication nurse • Separation of pressor from sedative • External auditory meatus horizontal to supraclavicular notch • Careful head positioning in the obese • RUQ ultrasound/ response to emesis • Load pressor line/early use of pressor

26. Combined Team Function • Used by military, police, fire fighters • For high risk/low frequency events • Characterized by CRM communication, simulation training, analysis of process • Can it be adapted to the ICU?

27. The Team • The team is composed of crew members • A crew is one or more in number and is highly skilled in their assigned task • The team leader is in overall charge and is trained in crew resource management

29. The EEI Team • The team leader: directs the crews, and performs the intubation • The airway crew (2): BVM ventilation • The medication nurse • The watcher: responsible for monitoring V.S./saturation and calling cutoffs • The supervisor: for advanced back-up

30. SBT with CPS for EEI • How to train the airway crew? • How to train the leader?

31. Training The Airway Crew • All medical interns receive individualized one on one SBT training • Perfect performance in BVM ventilation required at end of training • Mayo PH et al. Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Crit Care Med 2004 ;32:2422-7 • Results in an army of interns highly skilled in BVM ventilation

32. The Airway Crew • Critical element in EEI • Goal is to maximally saturate the patient to a stable plateau value before any attempt • Intubation function separate from BVM ventilation • Their function is to defend saturation

33. The Airway Crew • Absolutely critical to safe operation • Standard ACLS training completely ineffective • Intensive SBT training is key element to success

34. The Watcher • Calls out BP and saturation every 30 seconds • Red flags cut-off violation • Avoids inattention and distraction error • No other responsibility

35. Nurse Crew • Sets up medication, pumps, monitoring • Listens only to the leader • Calls back all orders • Medication nurse and the watcher need bedside briefing • Maintains situational awareness

36. Training the Leader • Repeated small group training in July • Each fellow rotates through each crew responsibility multiple times • Initial repeated task training, then interrupted SBT, finally full out SBT • No OR rotation for intubation training

37. Training the Leader • CPS used both as a simple task trainer and as full SBT device • Physical practice of setting up the environment, equipment, and personnel • Use of basic CRM • Video debriefing • Mastery of a comprehensive checklist

38. CRM • Call back all orders • Identification/briefing of crew members • Use of command voice/presence • No non-pertinent communication • Communication through team leader • Red flag all critical events • Post-event debriefing • Mandatory checklist • Situational awareness

39. The Checklist • Airway evaluation • Patient set-up • Equipment set-up • Personnel set-up • Pharmacology-up • Cut off/bail-out • Verification

40. Table 3. Checklist for emergency endotracheal intubation

41. Quality Assessment • Continuous saturation and blood pressure measurement • Audio recording of EEI • Formal scoring of audio • “You can run but you can’t hide”

42. Outcomes • Number of intubation attempts • Duration of intubation attempts • Verification of tube placement • Compliance with checklist • Hypotension • Hypoxemia • Complications

44. So What Happens if…. • The MICU team assumes responsibility for all EEI and does not “cherry pick”? • By policy, anesthesiology is not called….ever? • The team leader is a fellow trained with 20 hours of intensive simulation training? • The bagging team are two interns who are heavily pre-trained and have no other function?

45. What Happens if…. • There is mandatory 42 point check list? • CRM communication is standard? • There is a watcher, medicator and attending supervisor for true combined team tactics? • There is debriefing following each EEI? • An ongoing iterative process of quality improvement?

46. What Happens if…. • If there is truly accurate determination of the important endpoints of EEI • So that the team can work to improve safety • And not just blame the patient or notch up another “successful” intubation while there has been neuro injury that is covered up by a long MICU stay?

47. What Happens if…. • The EEI team recognizes that the patient is extremely vulnerable to brain injury and organ damage from…. HYPOXEMIA and HYPOTENSION • The EEI team focuses on defense of physiological function rather than the endotracheal intubation itself

48. Complications of EEI

49. Comment • Lowest complication rates compared to EEI reports in anesthesiology literature • Iterative process analysis combined with sequential quality improvement • Focus on defense of physiology • Combined team approach • Sustainable and transferable

50. Query #1: Ultrasonography? • Koenig SJ, Lakticova V, Mayo PH. Utility of ultrasonography for detection of gastric fluid during urgent endotracheal intubation. Intensive Care Med. 2011 ;37:627-31 • The last two deaths that I saw were related to death by drowning from unrecognized gastric content • Also useful for post intubation trouble shooting