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IMPROVING SAFETY OF TRACHEAL INTUBATION (TI) IN CRITICALLY ILL PATIENTS USING SCENARIO-BASED TRAINING (SBT) WITH A COMPUTERISED PATIENT SIMULATOR (CPS): RESULTS OF A QUALITY IMPROVEMENT PROGRAM

Beth Israel Medical Center, New York, NY

PURPOSE: Critically ill patients with hemodynamic and/or respiratory failure may require TI. SBT with CPS coupled with training in crew resource management (CRM) may be a promising approach to improving safety during TI, especially for junior fellows facing the challenge of TI in the unstable patient.

METHODS: Pulmonary/Critical Care fellows had multiple task training sessions with a CPS and learned to apply a predefined checklist of critical elements for safe TI. They had multiple SBT sessions for standard and complex TI including CRM strategy. For 8 months beginning August 2005, fellows used voice recorders to assess and score actual patient TIs. Compliance with the checklist, number and duration of intubation attempts, and verification of tube placement were scored. Continuous digital telemetry recorded changes in BP and saturation. In a separate program, medical interns received intensive training in correct bag-valve-mask ventilation using CPS. Nursing staff received specific role instruction. Each patient TI was followed by detailed debriefing with supervising attendings.

RESULTS: 100 TI were performed with fellows as team leader and primary intubator. 77 had adequate audio recording for scoring. Fellows completed 69/77 intubations; 8 required attending intervention. 46/69 TI were achieved on the first attempt. Fellows adhered well to the complex checklist. There were no major complications. 6/77 TI were difficult and were resolved with an airway stylet (5) or fiberoptic intubation (1). Intern BVM technique was excellent. Significant desaturation and/or hypotension occurred in a small proportion of patients who had extremely severe cardiopulmonary failure.

CONCLUSION: SBT with CPS/CRM is an effective technique in improving safety of TI. Fellows can be trained as highly competent team leaders and to deal with dangerous airway management emergently. Our results compare favorably with anesthesia literature under similar operating conditions.

CLINICAL IMPLICATIONS: TI is a high-risk procedure in the critically ill for which trainees must develop a high level of competence. Training programs should consider using intensive SBT with CPS/CRM to improve training.

DISCLOSURE: Abhijith Hegde, None.