Can Video Laryngoscopy Improve Trainee Success in Intubation?

Can Video Laryngoscopy Improve Trainee Success in Intubation?

Things aren’t the way they used to be.  When I was training, opportunities abounded for opportunities to intubate infants.  Then we did away with intubating vigourous infants born through meconium and now won’t be electively intubating them at all.  Then you can add in the move towards use of non-invasive respiratory support instead of intubating and giving surfactant and voila…you have the perfect barrier for training residents and others how to intubate.  On top of all of this the competition for learning has increased as the skill that was once the domain of the physician has now spread (quite rightly) to respiratory therapists, nurses in some places and with the growth of residency programs (ours is now 2.5X larger than when I trained) the scarce chances are divided among many.

Enter the Video Laryngoscope

To be clear this isn’t a post to promote a product but rather an examination of the effectiveness of a tool.  I am putting this out there recognizing the possibility that someone out there might have heard of or have been contemplating purchasing one of these items.  3467268_rdax_80Those that are quite proficient at intubation (likely trained in the “good old days”) would likely question the need for such a device but I believe the device isn’t really aimed at that group except to use perhaps as a teaching tool.  It really is targeted (at least I think) for those who don’t perform the skill often.

Does use of the video laryngoscope improve success rates at intubation?

This question has had an attempt now at being answered by Parmekar S et al in their paper Mind the gap: can videolaryngoscopy bridge the competency gap in neonatal endotracheal intubation among pediatric trainees? a randomized controlled study.  The study involved taking 100 pediatric residents and randomizing them into two groups.  The first would use the videolaryngoscope (VL group) and then intubate using the standard technique of direct laryngoscopy (DL group).  The second group started with DL and then changed to VL. Both groups took part in a training session on intubation and then participated in three simulation scenarios from NRP. Screenshot 2017-06-09 14.39.08.pngThe findings demonstrated a couple interesting things.  The first as shown in the graph was that the group that started with the laryngoscope had a near 90% success rate compared to about 60% for the traditional approach.  When the groups swapped though they were both equal in effectiveness. This suggests that by visualizing the airway with the VL students were able to identify structures better after doing so such that success was improved simply by having used the device.

The other finding worth mentioning was that when the times to intubation were looked at, there was no difference between the two groups at all.  If the intubation success is no different, why might the times be the same?  Having used the video laryngoscope myself it does take some getting used to.  Rather than looking directly at the airway you find yourself looking off to the side and adjusting the approach that is in front of you to place the ETT.  No doubt this does take some getting used to.

What I would have liked to see is a repeat assessment a week later after using a few more trials with the VL as I suspect once you are used to it the speed of intubation would improve as well.  I suppose though we will have to wait a little while until someone does such work but as a means of improving success in intubation I believe this tool has something to add.

 

Communication is certainly key

Communication is certainly key

If there is one thing that keeps coming back as a lesson again and again in life it is the importance of communication.  Whether it be in the home or at work, too many of our “problems” in the workplace come down to whether or not our teams talk to one another effectively.

A tremendous source of stress of course is the unknown. When a baby is born in the field we can only rely on the information being presented to us via telephone contact.  In the melee that occurs on arrival of a potentially sick patient, details can be missed.

The following video illustrates such a situation and I believe aptly provides a good example of how to communicate in such a way that the stress of the situation is relieved. If we can all strive to slow things down just a little we may find that communication eliminates much of the tension in such a situation.

If you are looking to “slow” down your life and improve things such as communication style you may want to have a look at the book “In Praise of Slow” as we head into the weekend.  It’s all about slowing things down to actually improve efficiency.  51giI-ZIOtL._SX332_BO1,204,203,200_The world is moving pretty quickly these days and couldn’t we all do with a little more efficiency and less wasted time?  In Neonatology we are confronted with surprises every day, often with little notice.  If we can slow things down and pass on the needed information to the right people at the right time we will help to reduce errors if we can just get it right the first time!

 

 

As you can tell I am a big fan of simulation in helping to create high functioning teams!  More of these videos can  be accessed on my Youtube channel at

All Things Neonatal YouTube

To receive regular updates as new videos are added feel free to subscribe!

Lastly a big thank you to NS, RH and GS without whom none of this would have been possible!

 

Improving information transfer. A team approach.

Improving information transfer. A team approach.

 

This post rings in another new video to add to the series on the All Things Neonatal YouTube channel.  I hope that you have gotten something out of the ones posted so far and that this adds something further to your approach to neonatal care.

The Golden Hour Revisited

In the last post to the video selections entitled A Golden Opportunity For Your NICU Team! the main thrust of the video was on the use of the Golden Hour approach to starting a baby on CPAP.  Having a standardized checklist based approach to providing care to high risk newborns improves team functioning for sure.  What do you do though when you need to hand off a patient to another team?  Depending on where you work this may not be an issue if the team performing the resuscitation is the team providing the care for the patient in the NICU.  Perhaps you work in a centre similar to our own where the team performing resuscitation is not the same as the one who will ultimately admit the patient.  You may also be in a location where there are no babies born on site but rather all patients are transferred in so in each case the patient is new to everyone on the receiving team.  How do you ensure that a complete hand over is done.

Out with the old and in with the new!

By no means do I want to imply that it is not possible to transfer information outside of the way that we demonstrate in this video.  What I do believe though is that with telehealth being available in more and more settings or without a formal support for the same, the use of smartphones make video conferencing a reality for almost everyone.  In most centres handovers have followed the practice of like communicating with like.  Nurses give report to nurses, respiratory therapists to each other and MDs to MDs.  What if there was another way though?  In the video below we demonstrate another approach.  Would it work for your team?

As you can tell I am a big fan of simulation in helping to create high functioning teams!  More of these videos can  be accessed on my Youtube channel at

All Things Neonatal YouTube

To receive regular updates as new videos are added feel free to subscribe!

Lastly a big thank you to NS, RH and GS without whom none of this would have been possible!

A Golden Opportunity For Your NICU Team!

A Golden Opportunity For Your NICU Team!

I have written about respectful communication before in Kill them with kindness.

The importance of collaborating in a respectful manner cannot be overemphasized, as a calm and well prepared team can handle just about anything thrown their way.  This past week I finally had the opportunity to take the 7th ed NRP instructor course.  4865-NRP323_ProductWhat struck me most about the new version of the course was not the approach to the actual resuscitation but the preparation that was emphasized before you even start!  It only takes 30 seconds to establish who is doing what in a resuscitation and while it would seem logical to divide up the roles each will take on it is something that has not been consistently done (at least in our institution).  When a baby is born and responds to PPV quickly, this may not seem that important but in a situation where a team is performing chest compressions, placing an emergency UVC and moving on to epinephrine administration it certainly is nice to know in advance who is doing what.

The Golden Hour

We and many other centres have adopted this approach to resuscitation and at least here developed a checklist to ensure that everyone is prepared for a high risk delivery.  While teams may think they have all the bases covered, when heart rates are racing it may surprise you to see how many times crucial bits of information or planning is missed.  As I told you in another post I will be releasing a series of videos that I hope others will find useful.  The video in this case is of a team readying itself for the delivery of a preterm infant that they anticipate will have respiratory distress.  Ask yourself as you watch the film whether your team is preparing to this degree or not.  Preparing in such a fashion certainly reduces the risk of errors caused by assumptions about who is doing what or what risk factors are present.

As you can tell I am a big fan of simulation in helping to create high functioning teams!  More of these videos can  be accessed on my Youtube channel at

All Things Neonatal YouTube

To receive regular updates as new videos are added feel free to subscribe!

Lastly a big thank you to NS, RH and GS without whom none of this would have been possible!

Practice Makes Perfect? Building Better Neonatal Teams.

Practice Makes Perfect? Building Better Neonatal Teams.

The following piece is by guest writer Nicole Sneath NNP at the University of Manitoba. I am delighted to have her write on the use of simulation in the NICU and encourage you to watch the video she made for a recent charitable luncheon for the Children’s Hospital Foundation of Manitoba.

Practice makes perfect. This is something we’ve all heard at one point or another. Whether it was when we were learning how to ride a bike without training wheels, or print our name, or pitch that perfect strike. It seems a basic lesson, common sense, but do we practice what we preach?

In health care we deal with stressful situations, complex syntheses of information and multiple unique interactions. For the most part, we work in interprofessional teams, each one responsible for some part of care to our patients and each one dependant on the other whether we like to admit it or not. Our groups are varied, ranging from hands on direct care providers, to consultants, support staff, administrators and maintenance workers. Each one plays a unique role complementing the other. Sounds like the perfect set up. In practice however, do we really complement each other? Do we communicate effectively? How often do things fall through the cracks? Do we use our skills and strengths to everyone’s advantage? Is this diverse system a well-oiled machine working together and collaborating to provide optimal patient care? I would guess if you looked at your organization critically you may not be happy with all the answers.

Most of us trained and practiced with members of our own profession, doctors with doctors, nurses with nurses and so on. We were hired into our jobs and again did our orientation and continuing education within our own groups. In the everyday workplace however we are all blended together, modeling those that have practiced before us. Sometimes we work together well, seamlessly collaborating for a common goal. When we don’t, who pays the price? Perhaps it’s the patient with an untoward outcome, perhaps its the administrator with a complaint on their desk, perhaps its the consultant frustrated by the miscommunications or perhaps it’s the staff member not satisfied or content with their work.

Training programs have started to recognize that collaboration needs to start at the beginning. Waiting to introduce these concepts until arrival into the workplace is too late. Interprofessional learning is defined as learning with, from and about each other and this should happen at all levels of education and training. Teams function well not only by practicing together, but by creating environments where teams can get to know each other. Creating a relationship, no matter how small, can go a long way when stress increases and trust is needed.

It’s been shown that errors are often caused by breakdowns in communication. Maybe the nurse that administered the wrong dose of medication just didn’t know the dosing for that particular medication? Solving the problem could be teaching the proper dose and voila, problem solved. Or was the problem that they didn’t know where to find the information, weren’t comfortable asking for help, or didn’t want to question the doctor that ordered it? When the surgeon amputates the wrong leg is it because that one surgeon just isn’t that bright? Or could it be that no one else in the operating room double-checked, no one spoke up when they thought-wait, was it the left or the right, each one assumed that someone else must know best? Speculations abound for what goes on in critical incidents such as these. A common thread in preventing many critical incidents is the need for improved communication. Closed-loop communication, a shared mental model, role identification and clear leadership are integral to good communication in stressful situations. These concepts are best taught through experience rather than didactic lectures alone. So how do we go about teaching these skills?

Practice. Practice in an environment that is like the real thing, but lacks the risk to patients. Gone is the see one, do one, teach one mantra but it is replaced by see many, simulate even more, then do. Simulation allows us to breakdown specific skills and practice them over and over until we master them. We can practice individually or to harvest the greater benefit we can bring our interprofessional groups together and practice the skills that can’t be taught by reading a book. We can video record the sessions and debrief them afterwards. Instead of debriefing by giving a reassuring pat on the back or a not helpful shaming, perhaps we should try the “debriefing with good judgement” method and gain insight into the frames that guide individuals behaviour and actions. We can stop asking “dirty questions”-you know, the questions that we ask when we already know the answer, the “guess what I’m thinking” questions. Instead we can develop true curiosity into what individuals are thinking and then be able to change behaviour and facilitate critical thinking and problem solving.

We all come to work and want to do a good job. We want to be told that we made a difference, that something we did during the day has made a positive contribution to someone’s life. If this doesn’t resonate then perhaps a change in occupation is in order. If we critically examine our own practice, we would find areas that we could improve, skills we wish were a little more precise, or areas of specialty that we wish we knew a little more about. Traditional responses would be to dust off an old textbook or perform a literature search and get the information we need. Is this manner of learning effective? Does this address all the skills and knowledge we are seeking? Do we really know our areas of weakness? Do we want to?

References

1.  There’s no such thing as “nonjudgemental” debriefing: a theory and method for debriefing with good judgement. http://www.ncbi.nlm.nih.gov/pubmed/19088574

2. Debriefing with good judgement: combining rigorous feedback with genuine inquiry.

http://www.ncbi.nlm.nih.gov/pubmed/17574196