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An application of the learning curve-cumulative summation test to evaluate training for endotracheal intubation in emergency medicine
Abstract
The learning curve-cumulative summation (LC-CUSUM) test allows for quantitative and individual assessments of the learning process. In this study, we evaluated the process of skill acquisition for performing endotracheal intubation (ETI) in three emergency medicine (EM) residents over a 2 year period in their first 2 years of their EM residency.
We evaluated 342 ETI cases performed by three EM residents using the LC-CUSUM test according to their rate of success or failure of ETI. A 90% success rate (SR) was chosen to define adequate performance and an SR of 80% was considered inadequate. After the learning phase, the standard CUSUM test was applied to ensure that performance was maintained.
The mean number of ETI cases required to reach the predefined level of performance was 74.7 (95% CI 62.0 to 87.3). CUSUM tests confirmed that performance was maintained after the learning phase.
By using the LC-CUSUM test, we were able to quantitatively monitor the acquisition of the skill of ETI by EM residents. The LC-CUSUM could be useful for monitoring the learning process for the training of airway management in the practice of EM.
... Statistical methods have been applied to analyze interventional and diagnostic LCs to overcome this issue. The cumulative summation (CUSUM) test and the LC-CUSUM test have been used multiple times for this purpose [9,[11][12][13]. However, to the best of the authors' knowledge, the LC-CUSUM test has not yet been well characterized in the ultrasound staging of endometrial cancer. ...
... The LC-CUSUM test was designed to inform when the operator performance is sufficiently far away from an unsatisfactory performance level to evaluate the performance as acceptable [11,13]. It supposes that a newcomer operator is not performing adequately at the start of monitoring. ...
... It supposes that a newcomer operator is not performing adequately at the start of monitoring. Afterward, it reports when the operator achieves a satisfactory level of performance [13,18]. Unlike LC-CUSUM, the CUSUM test is designed for monitoring the transition from an adequate to an inadequate performance level, and it can be used after LC-CUSUM to monitor whether the performance is maintained within an acceptable range [13]. ...
Purpose:
The learning curve cumulative summation (LC-CUSUM) test is commonly used as a quantitative assessment of the individual learning process. This study aimed to evaluate the skill acquisition process for performing ultrasound staging of endometrial cancer using the LC-CUSUM test.
Methods:
Sixty-seven ultrasound examinations performed by two operators were evaluated using the LC-CUSUM test according to their rate of success or failure to correctly stage myometrial invasion, serosa involvement, and pelvic and para-aortic lymph node involvement. The reference standard was the pathologic result. After the learning phase, the cumulative summation (CUSUM) test was applied to assess performance maintenance.
Results:
The processes achieved satisfactory performance in the majority of the cases according to the established definitions. Operator 1 reached adequate performance within the 30th procedure for all the locations considered, while operator 2 performed fewer than 30 ultrasound examinations by the audit time. The CUSUM test confirmed that the target quality was preserved after the learning phase. Moreover, the ultrasound staging for endometrial cancer was highly accurate.
Conclusion:
Using the LC-CUSUM test made it possible to monitor the achievement and maintenance of a satisfactory performance quantitatively. The LC-CUSUM test could be a valuable instrument to survey diagnostic pathways in gynecological ultrasonography quantitatively.
... In disciplines such as anesthesiology, pediatric critical care, and emergency medicine, between 26 and 75 intubations attempts are necessary to achieve intubation proficiency. [12][13][14][15] The number of intubations needed to develop procedural competence has not been defined for neonatal-perinatal medicine (NPM) fellows. ...
... This contrast is likely due to differences in definitions for procedural competence, which was set at a 90% first attempt success rate in other disciplines. [12][13][14][15]24 Consistent with previous neonatology literature, we defined competence more leniently, as an 80% success rate. 8,9 This was also informed by reported neonatology attending physicians' success rates of 64% for the first attempt and 72% to 88% within multiple attempts. ...
Objectives:
To characterize neonatal-perinatal medicine fellows' progression toward neonatal intubation procedural competence during fellowship training.
Methods:
Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows' intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success.
Results:
There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07-1.14).
Conclusions:
The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees' progression toward intubation competence is warranted.
... Similarly, a large single-center review of pediatric critical care trainees revealed that at least 50 endotracheal intubations are required to attain a 90% overall success rate in out-of-operating-room intubation [11]. One small study concluded that at least 75 procedures are required for emergency medicine trainees to achieve competence in emergent EI [12]. A recent analysis of close to 1000 ICU intubations performed predominantly by PCCM providers revealed a significant increase in the lowest oxygen saturation experienced by critically ill adults undergoing tracheal intubation between 100 and 200 previous operator EIs [13]. ...
... However, compared to those performed in the OR, EIs performed in the ICU are associated with challenging glottic visualization, higher incidence of "difficult" airways, increased the need for adjunct devices, lower first-pass success, higher incidence of complications, and higher failure rates [6]. Not surprisingly, trainee learning curves vary across environments, with competence in elective OR intubation reported after as few as 43 experiences, but far greater for non-elective procedures [10][11][12][13][14]16]. While OR EI experiences contribute to attainment of competence in this procedure, they may not offer sufficient situational, physiologic, or anatomic complexity to obviate the need for ICU EI experiences. ...
Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.
... In clinical settings, values derived from previous large series analysis (12) or based on expert agreement should be used. For instance, Je et al. (13) evaluated the performance of three residents while training on endotracheal intubation after agreeing that 90% of successful intubation was the goal to achieve and considering 80% as inadequately low. No matter which is the value you choose, it must make clinical sense. ...
... After defining the variable under control, determining the "benchmark" value is mandatory. This value can be determined by the quality manager (13) or can be estimated using the constant value obtained when the process is running correctly. In a dataset with a normally distributed mean, this standard value is the mean obtained when no out-of-the-statistical-limits cases had occurred (16). ...
Monitoring the quality of new or ongoing surgical activities is a necessity. Several Statistical Process Control (SPC) tools are available to professionals. Among them, Shewhart charts and cumulative sum charts (CUSUM charts) are useful methods to provide visual feedback before significant quality issues arise. In this paper, we discuss both methods based on our current approach. On Shewhart charts, one variable value is plotted on a time-series line. This method provides information about every single determination. Random variations of the values appear and by adjusting the adequate control limits it is possible to know whether those variations are random or out-of-control. Although large variations are easily detected, small but relevant changes are not. On the contrary, CUSUM charts have the capability of detecting small changes quickly. CUSUM is defined as a statistical tool that graphically represents the sequential monitoring of cumulative performance of any dichotomized or continuous variable under assessment. It emphasizes failures penalizing them against the correct performance when individual risk is adjusted. This makes CUSUM especially sensitive to negative changes. CUSUM can be created without the need of a specific sample size and grow with every new case included. Besides the variable under control (with specific definitions of acceptable and unacceptable outcomes), the type I and II errors for the defined parameter and the individual risk of acceptable or unacceptable outcomes must be included in the chart. Graphical representation of these three parameters is easy and intuitive to read making CUSUM graphs a reliable tool to understand the trending of the parameter under control. If performance is considered inadequate: analysis, discussion and implementation of agreed measures should be taken. Despite its limitations, CUSUM analysis is considered the best tool for quality control in health care domain.
... This method has been applied to the analysis of the LC and quality control for monitoring clinical performance. [5] Additionally, to the best of our knowledge, LC-CUSUM analysis of competence and quality of visual estimation of LV function through echocardiographic video images in the ED has not yet been studied in the emergency medicine literature. ...
... Most previous studies using CUSUM analysis dichotomized the decision parameter, for example, whether trainees correctly diagnosed a condition (acceptable measurement, success or failure); however, we classified the decision parameter into 4 categories (normal, mildly reduced, moderately reduced, and severely reduced). [5,[10][11][12][13][14][15] We believe that this detailed categorization could more accurately reflect the practitioner's skill level than dichotomous classification. ...
The aim of the present study was to determine the value of cumulative summation (CUSUM) analysis in assessing the proficiency of novice practitioners in estimating the left ventricular ejection fraction (EF).
Seven novice practitioners with no echocardiography experience were recruited in this observational study. Each practitioner assessed EF from echocardiographic video files of 100 cases, one by one, and received feedback and teaching. We obtained a CUSUM score through comparison of the gold standard values of EF and the EF values determined by the practitioners. Then, the practitioners underwent the same test 4 weeks later, except without feedback and teaching, using echocardiographic video files from 100 other cases.
The mean number of visual estimation cases required to pass the learning curve (LC)-CUSUM test was 56.3 ± 9.1 (95% CI 47.8–64.7). The LC-CUSUM average of the 7 novice practitioners showed improvement in visual estimation skill, with an average acceptable level achieved after a mean experience of 55 cases. In the test performed after 4 weeks, 5 of the 7 novice practitioners showed significantly good overall agreement. All novice practitioners had a kappa coefficient greater than .8, and significant and almost perfect agreement was observed. All the participants exhibited a percentage of correct answers greater than 81%.
We found that the novice practitioners could acquire an acceptable level of skill for estimating EF with short-term, self-learning-focused echocardiographic training.
... Failure to complete a procedure is associated with increased risk of patient safety events (4)(5)(6)(7). PCCM and similar medical specialties, such as Anesthesiology and Emergency Medicine, have determined a minimum number of procedures before an expected competency (success for completing a given procedure) for a given procedure would be obtained (8)(9)(10)(11). ...
... Our data did not demonstrate a decrease in rates of intubation. In medical specialties that perform similar procedures to PCCM, such as Anesthesiology and Emergency Medicine, authors have described the number of intubations required to achieve competence and a mean of 44-74 tracheal intubations achieved 80-90% competency within one-two attempts (8)(9)(10). During PCCM Fellowship training a median of 26 tracheal intubations outside of the operating room were needed to achieve 90% competency within four attempts (11). ...
Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions.
Objective: Our hypothesis was that over the past decade the rate of procedures performed by Pediatric Critical Care Medicine Fellowship trainees decreased.
Methods: Retrospective review at a single institution, tertiary, academic, children's hospital of patients admitted from July 1, 2007–June 30, 2017 to the Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit. A Poisson regression model with a scale adjustment for over-dispersion estimated by the square root of Pearson's Chi-Square/DOF was applied.
Results: There has been a statistically significant decrease in the average rate of central venous lines (p = 0.004; −5.72; 95% CI: −9.45, −1.82) and arterial lines (p = 0.02; −7.8; 95% CI: −13.90, −1.25) per Fellow per years in Fellowship over the last 10 years. There was no difference in the rate of intubations per Fellow per years in Fellowship (p = 0.27; 1.86; 95% CI:−1.38, 5.24).
Conclusions: There has been a statistically significant decrease in the rate of central venous lines and arterial lines performed by Pediatric Critical Care Medicine Fellowship trainees per number of years in Fellowship over the last 10 years. Educators need to be constantly reassessing the clinical landscape in an effort to make sure that trainees are receiving adequate educational experiences as this has the potential for an impact on the education of trainees and the safety of the patients that they care for.
... It assumes the evaluated process is not successfully conducted at the start of monitoring and signals when the trainee can be considered to be competent. It has been used to evaluate the learning process of several medical procedures [19,20]. It has a holding barrier at zero. ...
... The arbitrary choice of 100 lesions could be insufficient to reach the demanding 90% threshold, but the 0.96 ICC found in the diagnostic accuracy phase showed evaluators presented a very high agreement in their hits and misses, suggesting misconceptions generated in the learning phase were not corrected during the diagnostic accuracy evaluation phase by those reviewing their diagnosis. Further studies are required to address if specific training aimed at small polyps would suffice to allow the LC-CUSUM to adequately certify a successful learning process, as shown in studies evaluating other medical procedures [19,20]. It is also unknown if once the desired accuracy threshold is reached, further periodic evaluations are needed. ...
Background and aims:
Accurate optical diagnosis of diminutive polyps would allow implementing a resect and discard strategy. We evaluated the learning curve of a single training session followed by self-education in subjects with no endoscopic experience.
Methods:
Learning curves were evaluated in 38 subjects employing learning curve-cumulative summation (LC-CUSUM) tests, with each participant attending one training session regarding narrow band imaging and optical diagnosis and then individually assessing 100 lesions, receiving feedback after each diagnosis. Diagnostic accuracy was subsequently evaluated in 180 patients with lesions ≤ 7 mm. Evaluators predicted each polyp's histology and recommended a surveillance interval. Determinants of accuracy were explored using regression analysis.
Results:
According to the LC-CUSUM curve, 20 evaluators (52.6%) reached diagnostic competence after 57 lesions (IQR 55-76.5). During the diagnostic performance assessment, 11,666 diagnoses and 6840 follow-up recommendations were generated. Considering high confidence diagnoses, accuracy was 81.3% (80.5-82.1%), negative predictive value (NPV) for rectosigmoid adenomas 78.6% (76.4-80.6%), and sensitivity for adenomas 86.6% (85.8-87.4%). Two (5.3%) evaluators reached a ≥ 90% accuracy, 3 (7.9%) presented a NPV for rectosigmoid adenomas ≥ 90%, and 18 (47.4%) a sensitivity for adenomas ≥ 90%. Multivariable logistic regression showed high confidence and size ≥ 5 mm as the strongest predictors of accuracy. Fifteen (39.5%) evaluators recommended a correct or reduced follow-up interval in over 90% of subjects.
Conclusions:
Self-formation after a single training session did not allow most evaluators to reach the required accuracy. LC-CUSUM tests did not identify competent evaluators. Despite these results, 86.7% of follow-up intervals would have been corrected or reduced.
... An example of this is endotracheal intubation in the ED, for which a 90% success rate was found in one study to require 75 attempts. 24 Such methods have their obvious limitations including access to procedures, number of different procedures and patient complexity. It is also clear that on the whole, competence is difficult to define (what rate of shoulder relocation or complication would be considered competent?) ...
... and differs markedly between trainees. 24,25 The DOPS assessment tool was created by the Royal College of Physicians with literature supporting its validity and reliability. 26 As such, it is seen as the standard measure of procedural competency for the critical care colleges in Australasia. ...
... Around 25 million ETI procedures are performed in the USA per year. Training is needed in order to reach proficiency, with some authors suggesting that up to 75 procedures are required [1], whilst ETI failure is associated with potentially life-threatening complications. Of note, ETI performed in neonates and children is even more complex and more procedures may be required to achieve expertise. ...
These authors contributed equally to this work. Abstract: Background: Training is required to achieve proficiency in airway management. Simulators are of utmost importance not only for the purpose of training novices, but also for evaluating newer airway devices and techniques. Growing evidence supports inadequate anatomic airway reproduction in adult and pediatric manikins. Methods: We conducted an observational study comparing 17 radiological anatomic airway measurements obtained via the computed tomography of three commercially available manikins with the same measurements obtained from a population of newborns/infant (range: 0-3 months) undergoing magnetic resonance imaging for diagnostic purposes. According to the reference (mean and standard deviation (SD) of the pediatric population), each manikin measurement was defined as adequate, partially adequate or inadequate (difference between means: ≤±1, 1.0-1.96 or >1.96 SD, respectively). The primary outcome was the number of measurements with an adequate reproduction of airways. Results: We included 27 pediatric patients (21 ± 19 days, 48% males, 46.6 ± 3.5 cm, 2.7 ± 0.5 Kg and 12.6 ± 2.9 kg/m 2). All manikins had n = 11/17 measurements with inadequate airway anatomic reproduction. The three measurements with more adequate reproduction were the height of the soft palate, retropalatal airspace volume and tongue volume (adequate in two manikins, and partially adequate in the remaining one). Conclusions: In three manikins commonly used for training in pediatric airways, static dimensions do not seem anatomically correct in relation to those of pediatric patients. Such inaccuracies may introduce biases in airway device development as well as in training.
... [1][2][3] For this reason, well-trained and experienced medical staff are responsible for performing tracheal intubation in the emergency department. [4] Nevertheless, the COVID-19 pandemic is changing emergency airway management in the emergency department and intubation training for novice practitioners. ...
The aim of this study was to determine which of 4 laryngoscopes, including A-LRYNGO, a newly developed channel-type video-laryngoscope with an embedded artificial intelligence-based glottis guidance system, is appropriate for tracheal intubation training in novice medical students wearing personal protective equipment (PPE).
Thirty healthy senior medical school student volunteers were recruited. The participants underwent 2 tests with 4 laryngoscopes: Macintosh, McGrath, Pentax Airway-Scope and A-LRYNGO. The first test was conducted just after a lecture without any hands-on workshop. The second test was conducted after a one-on-one hands-on workshop. In each test, we measured the time required for tracheal intubation, intubation success rate, etc, and asked all participants to complete a short questionnaire.
The time to completely insert the endotracheal tube with the Macintosh laryngoscope did not change significantly (P = .177), but the remaining outcomes significantly improved after the hands-on workshop (all P < .05). Despite being novice practitioners with no intubation experience and wearing PPE, the, 2 channel-type video-laryngoscopes were associated with good intubation-related performance before the hands-on workshop (all P < .001). A-LRYNGO's artificial intelligence-based glottis guidance system showed 93.1% accuracy, but 20.7% of trials were guided by the vocal folds.
To prepare to manage the airway of critically ill patients during the coronavirus disease 2019 pandemic, a channel-type video-laryngoscope is appropriate for tracheal intubation training for novice practitioners wearing PPE.
... [1,[15][16][17] As documented by various authors, average of 57 attempts needed to achieve a 90% success rate of intubation. [14,18,19] Various studies are indicating conceivable connection between operator's tracheal intubation experience and patient outcome. [20][21][22] There is little information in the literature that indicates the extent of training required for competence in laryngoscopy and tracheal intubation. ...
Background and Aims: To evaluate the role of experience in acquisition of skill of orotracheal intubation in adults.
Material and Methods: A prospective randomized study was conducted on 307 patients of either sex, belonging to ASA grade I and II (aged 18-60 years) posted for surgery under general anaesthesia. The patients were subjected to DL and ETI procedure, which was performed by five different groups of participants. Group 1 consisted of first-year resident of anaesthesiology with experience of less than 10 intubations, group 2 for second-year resident, group 3 for third-year resident, group 4 for senior resident and group 5 for consultant. Ease of mask ventilation, time taken for intubation, number of attempts, success rate, and ease of intubation were assessed for all the groups.
Results: Categorical variables were analysed using Chi-square test. For all statistical tests, a P value less than 0.05 was taken as a significant difference. Maximum difficulty in mask ventilation was encountered by group 1 anaesthesiologist, that is, in 69.2% of the patients. Group 1 took maximum time to intubate, that is, 47.98 ± 31.54 sec and least time was taken by group 5 anaesthesiologist (9.55 ± 6.93) sec. First attempt success rate was least in group (80.0%). Group 1 had success rate of 96.9%, whereas rest all groups had 100% success.
Conclusion: Skill of mask ventilation and intubation and time taken for intubation grossly improves with increasing experience. Minimum of 25 intubation attempts should be required by an anaesthesiologist resident in elective scenario to achieve 100% success rate in our study.
... Variability in assessment likely exists among programs and residents, and there is no agreedupon standard of completion or complication rate. 20,21 While the evaluation of performance on this new EI rotation would be useful information to have, it is beyond the scope of the study. Our project was not designed to evaluate performance or competence. ...
INTRODUCTION
The American College of Graduate Medical Education (ACGME) defines 18 “key procedures” as requirements in emergency medicine (EM) residency programs. The post-graduate year-1 (PGY-1) curriculum provides an early foundation for EM trainees to gain procedural experience, but traditional PGY-1 rotations may not provide robust procedural opportunities. Our objective was to replace a traditional orthopedic rotation with a 4-week rotation that emphasized EM procedure acquisition and comprehension. Although all residents met ACGME procedural requirements before the curricular modification, the purpose of this month was to increase overall procedure numbers. The block contained dedicated procedure shifts in the emergency department as well as an asynchronous, self-directed learning course. We sought to compare the number of procedures performed by PGY-1 residents during their orthopedic rotation (the year before implementation), to the number of procedures performed during their procedure rotation (the year after implementation).
METHODS
The total number of procedures performed and logged by PGY-1 residents during the traditional orthopedic rotation (during the year prior to implementation of the new procedure rotation) were compared to the total number of procedures by the first class to undergo the new procedure rotation the following year. Thirty resident logs were reviewed (15 per class). Data were analyzed using SAS NPAR1WAY; Z < 0.05 was considered significant.
RESULTS
When compared to the orthopedic rotation, the procedure rotation had statistically significant higher numbers of procedures per resident (22, standard deviation [SD] 12, vs 11.4, SD 7.6; Z = 0.0177). A wide variety of nonorthopedic procedures accounted for the increased numbers, (13.6, SD 10.3, vs 0.9, SD 0.9; Z < 0.001). While the average number of orthopedic procedures was slightly less on the procedure rotation, there was no statistical difference (orthopedic rotation 10.13, procedure rotation 8.26; Z = 0.4605). Notably, fewer procedures were performed when 2 residents were on the procedure rotation at the same time (21 vs 10.1).
CONCLUSION
This analysis demonstrated a larger number and a wider variety of procedures performed by PGY-1 residents during a dedicated procedure rotation compared to a traditional orthopedic rotation. Furthermore, exposure to orthopedic procedures did not decline significantly. Limitations of the study include a modest number of subjects. Data may be limited by the consistency of procedure logging by individual residents. Further studies may assess procedural competency after PGY-1 year of training.
... As such, a first step in measuring the real-time efficiency and identifying bottlenecks in NGS and bioinformatics pipelines could be to adopt statistical process control (SPC) methods such as cumulative sum (CUSUM) (14), or exponentially weighted moving average (EWMA) (15), to monitor the temporal parameter stability and identify structural breakpoints in TAT. CUSUM is a sequential analysis technique which monitors change detection, particularly deviation from a performance standard (16)(17)(18), and has been widely used in a range of healthcare settings, from describing the learning curves of surgical or procedural skills (19)(20)(21)(22)(23)(24), to clinical audits (25)(26)(27), and quality-assurance studies (22,(28)(29)(30)(31)(32). Similar to CUSUM, EWMA control charts have been widely used for measuring and monitoring healthcare outcomes (33,34). ...
Purpose: Precision oncology, such as next generation sequencing (NGS) molecular analysis and bioinformatics are used to guide targeted therapies. The laboratory turnaround time (TAT) is a key performance indicator of laboratory performance. This study aims to formally apply statistical process control (SPC) methods such as CUSUM and EWMA to a precision medicine programme to analyze the learning curves of NGS and bioinformatics processes.
Patients and Methods: Trends in NGS and bioinformatics TAT were analyzed using simple regression models with TAT as the dependent variable and chronologically- ordered case number as the independent variable. The M-estimator “robust” regression and negative binomial regression were chosen to serve as sensitivity analyses to each other. Next, two popular statistical process control (SPC) approaches which are CUSUM and EWMA were utilized and the CUSUM log-likelihood ratio (LLR) charts were also generated. All statistical analyses were done in Stata version 16.0 (StataCorp), and nominal P < 0.05 was considered to be statistically significant.
Results: A total of 365 patients underwent successful molecular profiling. Both the robust linear model and negative binomial model showed statistically significant reductions in TAT with accumulating experience. The EWMA and CUSUM charts of overall TAT largely corresponded except that the EWMA chart consistently decreased while the CUSUM analyses indicated improvement only after a nadir at the 82nd case. CUSUM analysis found that the bioinformatics team took a lower number of cases (54 cases) to overcome the learning curve compared to the NGS team (85 cases).
Conclusion: As NGS and bioinformatics lead precision oncology into the forefront of cancer management, characterizing the TAT of NGS and bioinformatics processes improves the timeliness of data output by potentially spotlighting problems early for rectification, thereby improving care delivery.
... EAM is a difficult skillset to master, requiring extensive hands-on training with human patients and extensive clinical experience. 22,23 Airway management experiences in the elective setting certainly enhance a trainee's ability to perform in the emergency setting, especially regarding technical knowledge and skill. However, it is important to recognize that a number of factors are different in the emergency airway setting. ...
Emergency airway management (EAM) is a “high stakes” clinical practice, associated with a significant risk of procedure-related complications and patient mortality. Learning within the EAM team practice is complex and challenging for trainees. Increasing concern for patient safety and changes in the structure of medical education have resulted in educational challenges and opportunities for improvement within the EAM team practice. This paper is divided into 3 sections that describe the past, present, and future of the EAM team learning practice within a large academic institution. Section 1 provides a brief overview of the evolution of the existing practice of EAM. Key features, goals, and challenges of the practice are outlined and a recently performed needs analysis to identify areas for improvement is described. Section 2 examines the underlying assumptions regarding learning within the existing practice and explores how these assumptions fit into major theories of learning. Section 3 proposes an idealized learning practice for the EAM team which includes the assumptions regarding learners, design of the learning environment, use of technology to enhance learning, and the means of assessment and measuring success. It is hoped that through this systematic exploration of the EAM team practice, learning efficacy and efficiency will be improved and remain adaptable for challenges in the future.
... Using CUSUM and a cutoff failure rate less than 20%, the number of intubations from these studies suggest that between 22 and 45 attempts are needed to achieve this target, allowing for multiple passes, external coaching, and assistance [36,37,40,42]. When choosing a more conservative failure rate of less than 10%, the number jumps to 57 to 75 attempts, with continued improvement being seen after 100 procedures [35,45]. For a more detailed analysis of these studies and others targeting emergency response personnel, see the recent systematic review by Buis and colleagues [46]. ...
Anesthesiologists will continue to be recognized as airway experts and other specialties will need ongoing access to the clinical volume available in the OR setting when looking for opportunities to meet their residents’ and fellows’ airway management training needs. At the same time, critical care, EM, and other physicians have acquired an ever-expanding array of skills and experience managing the airways of critically ill and injured patients. When considering the needs of nonanesthesiologist trainees coming to our domain, it is essential to recognize the differences inherent in practicing outside of the OR and to incorporate those aspects of airway management considerations into training paradigms. This should be viewed as an opportunity to work toward a more universal approach to training and airway management in our individual institutions incorporating a multidisciplinary approach to education and clinical activities.
... Intubation success generally depends on the experience of the provider [22,23]. ETI success rates are higher when a physician performs the procedure as compared with paramedics or nurse providers [24][25][26], which may partly explain the high IFI success rate we observed. ...
Introduction:
The Helicopter Emergency Medical Service (HEMS) commonly intubates patients who require advanced airway support prior to takeoff. In-flight intubation (IFI) is avoided because it is considered difficult due to limited space, difficulty communicating, and vibration in flight. However, IFI may shorten the total prehospital time. We tested whether IFI can be performed safely by the HEMS.
Methods:
We conducted a retrospective cohort study in adult patients transported from 2010 to 2017 who received prehospital, non-emergent intubation from a single HEMS. We divided the cohort in two groups, patients intubated during flight (flight group, FG) and patients intubated before takeoff (ground group, GG). The primary outcome was the proportion of successful intubations. Secondary outcomes included total prehospital time and the incidence of complications.
Results:
We analyzed 376 patients transported during the study period, 192 patients in the FG and 184 patients in the GG. The intubation success rate did not differ between the two groups (FG 189/192 [98.4%] vs. GG 179/184 [97.3%], p = 0.50). There were also no differences in hypoxia (FG 4/117 [3.4%] vs. GG 4/95 [4.2%], p = 1.00) or hypotension (FG 6/117 [5.1%] vs. GG 5/95 [5.3%], p = 1.00) between the two groups. Scene time and total prehospital time were shorter in the FG (scene time 7 min vs. 14 min, p < 0.001; total prehospital time 33.5 min vs. 40.0 min, p < 0.001).
Conclusions:
IFI was safely performed with high success rates, similar to intubation on the ground, without increasing the risk of hypoxia or hypotension. IFI by experienced providers shortened transportation time, which may improve patient outcomes.
... Intubation success generally depends on the experience of the provider [23] [24]. Compared with paramedical or nurse providers, ETI success rates are higher when the physician performs the procedure [25][26] [27], which may partly explain our high IFI success rate in the study. ...
Introduction: Endotracheal intubation is an essential skill in emergency medicine requiring technical proficiency and sufficient preparation for a safe procedure. In the Helicopter Emergency Medical Service (HEMS), it is common to intubate the patient who needs an advanced airway prior to take-off. In-flight-intubation (IFI) is avoided because it is considered difficult due to environmental limitations of space, communication, and vibration. In contrast, IFI may shorten the total prehospital time since the procedure is conducted during the flight. We tested whether IFI can be performed safely and shorten transportation time.
Methods: We conducted a retrospective cohort study with patients transported from Apr 2010 to Mar 2017 in a single center. We included patients ≥ 18 years who received prehospital intubation and excluded patients with emergent intubation at the scene. We divided the observational cohort into two groups. The Flight group (FG): included patients intubated during the flight. The Ground group (GG): included patients intubated prior to take-off. HEMS crews transported both groups. The primary outcome was the proportion of successful intubations. Secondary outcomes included total prehospital time and the incidence of complications such as hypoxia and hypotension.
Result: We analyzed 376 patients during the study period. There were 192 cases in FG and 184 cases in GG. Intubation success rate did not differ between the two groups (FG vs GG: 98.4% vs 97.3%, p = 0.50). There were no differences in hypoxia (FG vs GG: 3.4% vs 4.2%, p = 1.00) or hypotension (FG vs GG: 5.1% vs 5.3%, p = 1.00) between two groups. Scene time was shorter in FG (FG vs GG: 7 min vs 14 min, p < 0.001), as was total prehospital time (FG vs GG: 33.5 min vs 40.0 min, p < 0.001).
Conclusions: In-flight-intubation during HEMS could be safely performed without additional hypoxia or hypotension. In-flight-intubation by experienced providers shortened transportation time by an average of 7 minutes.
... In comparison, during training, Bucher et al 22 reported that emergency medicine residents averaged 29 intubations per year (with one resident performing 157 intubations in 1 y), which is much higher than the number of intubation opportunities provided to RTs. Je et al 23 reported that 74 intubations were needed for emergency medicine residents to achieve proficiency. A study of pediatric critical care fellows found approximately 51 intubations were required to achieve competence. ...
Background:
Endotracheal intubation is a common procedure performed by respiratory therapists (RTs). The purpose of this study was to describe current RT intubation practices in North Carolina through the use of a survey instrument.
Methods:
A survey was developed by the authors using REDCap. The survey was sent via email to all licensed RTs in North Carolina. Information collected included respondent demographics, intubation practices (including training and skill maintenance), and attitudes about RT intubation practices.
Results:
Of the 411 respondents, 68% intubated at their facility, representing 81 unique institutions. RTs who performed intubation were more likely to be from community hospitals and less likely to be from level 1 trauma centers. Respondents reported intubating adult (91%), pediatric (61%), and neonatal (65%) patients. The most common areas in which RTs reported performing intubation were the adult ICU (80%), emergency department (76%), outside the operating room for emergencies (76%), neonatal ICU (43%), the delivery room (45%), and pediatric ICU (25%). The median (interquartile range) number of supervised intubations required to be considered competent was 5 (3-5). The most common numbers of intubations required to be considered competent were 5 (32%), 3 (26%), 10 (16%), 2 (4%), and 0 (3%). The perceived number of intubations to achieve competence was 6 (range 5-10) and did not differ based on years of experience. Most respondents believed their RT intubation program was safe (93%) and effective (91%), and that RTs were well-trained (81%), that their intubation skills were objectively evaluated (66%), and that RTs receive sufficient feedback on performance (68%).
Conclusions:
RTs in North Carolina frequently performed intubation and had high confidence in their programs. Further studies are needed to establish standardized training for endotracheal intubation, document success rates for intubations, and evaluate the use of video laryngoscopy by RTs.
... Another significant result of the research is the fact that paramedics were able to intubate using a videolaryngoscope after short training effectively. In the case of direct laryngoscopy, the learning curve, as shown by numerous studies, illustrates 43-75 attempts required for achieving successful intubation (34)(35)(36). The present study indicates an acceleration of the learning curve with videolaryngoscopy, and this is also confirmed in studies by Baciarello et al. (37), Aghamohammadi et al. (38), and other authors (13,39,40). ...
... The intricate procedure involves the provider using a laryngoscope to apply forceful leverage on the upper airway structures in order to obtain visualization of the vocal cords and pass the endotracheal tube through the glottic opening and into the trachea, thereby securing a patent pathway for respiration. Consequently, ETI is a difficult skill to acquire and maintain and evidence suggests that obtaining a 90% proficiency rate requires experience with 75 intubation cases (Je et al., 2015), a number of cases which is often unattainable for many prehospital providers. Without sufficient training and experience, significant complications, such as hypoxia, hypotension, aspiration, and cardiac arrest, may occur. ...
Loss of a patent airway is a significant cause of prehospital death. Endotracheal intubation is the gold standard of care but has a high rate of failure and complications, making development of new devices vital. We previously showed that tracheal tissue has a unique spectral profile which could be utilized to confirm correct airway device placement. Therefore, the goals of this study were twofold: 1‐ to develop an airway obstruction model and 2‐ use that model to assess how airway compromise affects tissue reflectance. Female swine were anesthetized, intubated, and instrumented. Pigs were allowed to breathe spontaneously and underwent either slow‐ or rapid‐onset obstruction until a real‐time pulse oximeter reading of ≤50%. At baseline, 25%, 50%, 75%, and 100% obstruction, a fiber‐optic reflection probe was inserted into the trachea and esophagus to capture reflectance spectra. Both slow‐ and rapid‐onset obstruction significantly decreased arterial oxygen concentration (sO2) and increased partial pressure of CO2 (pCO2). The presence of the tracheal‐defining spectral profile was confirmed and remained consistent despite changes in sO2 and pCO2. This study validated a model of slow‐ and rapid‐airway obstruction that results in significant hypoxia and hypercapnia. This is valuable for future testing of airway device components that may improve airway management. Additionally, our data support the ability of spectral reflectance to differentiate between tracheal and esophageal tissues in the presence of a clinical condition that decreases oxygen saturation. Endotracheal intubation is the gold standard of care but requires confirmation of correct placement. We hypothesized that white‐light reflectance may be used as a technique to confirm placement in the trachea. Our data confirm that spectral reflectance can distinguish tracheal from esophageal tissue even in the face of changing levels of oxygen and carbon dioxide during airway obstruction.
... Therefore, the inherent failure rate and risk factors, including external laryngeal pressure, CL classification, and intubation-related adverse events, were both defined as 2%. [17,18] ...
Background:
Endotracheal intubation (ETI) is a life-saving procedure taught to medical students. We examined the influence of the order of teaching ETI through direct laryngoscopy (DL) and video laryngoscopy (VL) on learning by measuring the intubation time and learning curve of trainees, in order to explore ways to improve ETI performance.
Methods:
Twenty trainees were randomly divided into 2 groups. In the DL-first group, trainees used DL to perform ETI 10 times and then used VL 10 times, while the order was reversed in the VL-first group. Intubation time, number of intubation attempts, the Cormack-Lehane (CL) classification, and adverse events were recorded. The primary outcome was the cumulative summation (CUSUM). The CUSUM equation is defined as (Equation is included in full-text article.), where ct is the cumulative sum.
Results:
ETI was attempted on 400 patients. The difference in the mean times for the first 10 intubations between the 2 groups was not significant (P > .05). Mean intubation time for second series in the DL-first group was significantly shorter than that of the first series (P < .05), while there were no differences between the 2 series in the VL-first group (P > .05). The mean intubation time in the second series of the DL-first group was shorter than for the first series of the VL-first group (P < .05), while the mean intubation time of the first series by the DL-first group did not differ from the second series by the VL-first group (P > .05). Eighteen attempts were required to achieve an 80% intubation success rate for the DL-first group, while more than 20 attempts were required for the trainees in the VL-first group.
Conclusion:
We consider that teaching trainees DL for tracheal intubation first.
Clinical trial number:
ChiCTR-OOR-16008364.
... All physicians involved had experienced at least 60 cases of ETI in the ED before this study. (14) Data acquisition Chart review was performed by 2 particularly trained chart reviewers. They were blinded to the hypothesis and outcome of this study and performed chart review individually. ...
... On the positive side, the proportion of successful intubations in the study increased steeply in relation to the reported number of previous clinical attempts, consistent with existing evidence that previous intubation experience is associated with subsequent success. 3,7 However, neither our study nor the literature [8][9][10][11] suggests that 20 prior attempts might reliably predict subsequent success, even in a controlled, supervised environment. Given the reduced numbers of tracheal intubations performed for elective surgical cases for which supraglottic airway devices are used, adequate supervised training may not be achieved within the locally recommended 12 40 general anaesthetics required within a two-month anaesthetic internship. ...
Background: Tracheal intubation is an essential skill for anaesthetists and other disciplines that require emergency establishment of a secure airway. Early attempts in patients often meet with failure. Existing publications focus mainly on trainees in emergency settings and highlight the role of experience in success; most recommend prior simulation training. Common factors identified as contributing to difficulty have been difficult airways, emergencies and rapid sequence induction. Early intubation skill development in patients with anticipated straightforward airways in a controlled environment has received little attention.
Objectives: This qualitative observational study aimed to identify common difficulties associated with a supervised intubation process by inexperienced personnel in the relatively stress-free conditions of elective surgical procedures in the operating theatre.
Methods: Following institutional and ethical approval, participants, supervisors, anaesthetic assistants and patients consented to observation and video-recording of supervised intubations in a Durban teaching hospital. Anonymity and confidentiality were assured. Contemporaneous observations were recorded in theatre, and video-recordings were subsequently reviewed for content. Errors, and interactions between supervisor, assistant and participant, and associated outcomes, were identified.
Results: Twenty participants (medical interns and medical, paramedical and nursing students) performing 72 intubations were observed. All participants had prior training using manikins or simulators. There were 61 successful intubations and 11 unsuccessful attempts. Factors associated with failure included unfamiliarity with airway, equipment or process. Process errors included inadequate head positioning, laryngoscope handling and tracheal tube manipulation. Anaesthetic assistants contributed to difficulties in some cases. Supervisor support was either verbal, physical or both. Less experienced supervisors tended to intervene earlier. There was a significant trend for success associated with the reported number of prior successful intubations. A successful intubation within the study was, however, no guarantee of subsequent success.
Conclusion: Despite prior simulation training, many participants demonstrated lack of familiarity with the airway, intubation process and equipment. While improved simulation training might partly address these issues, supervision of early clinical intubation attempts needs to be redirected from the process of intubation itself to the process of intubation skills acquisition. A first step would be to ensure that all supervisors and assistants are trained for the latter goal, anticipating common errors and providing standardised conditions for success. The use of video-recording of the events is an invaluable aid to observation and interpretation, and is recommended as an adjunct to further studies of mechanical skills transfer.
Changes in neonatal intensive care unit (NICU) coverage models, restrictions in trainee work hours, and alterations to the training requirements of pediatric house staff have led to a rapid increase in utilization of front-line providers (FLPs) in the NICU. FLP describes a provider who cares for neonates and infants in the delivery room, nursery, and NICU, and includes nurse practitioners, physician assistants, and/or hospitalists. The increasing presence and responsibility of FLPs in the NICU have fundamentally changed the way patient care is provided as well as the learning environment for trainees. With these changes has come confusion over role clarity with resulting periodic conflict. While staffing changes have addressed a critical clinical gap, they have also highlighted areas for improvement amongst the teams of NICU providers. This paper describes the current landscape and summarizes improvement opportunities with a dynamic neonatal interprofessional provider team.
Objective:
Laryngoscopy simulators quantifying forces on critical structures in progressively challenging airways and operator expertise are lacking. We aimed to quantify laryngoscopy forces across expertise and exposure difficulty.
Study design:
Prospective observational study Setting: Tertiary care medical center Methods: Force gauges were affixed to a difficult airway mannequin to quantify teeth and tongue forces across increasingly challenging airway exposure. Medical students (n=10), residents (n=11), and otolaryngology staff (n=10) performed direct laryngoscopy using a Miller size 3 laryngoscope with 1) normal neck/jaw mobility, 2) restricted neck extension, 3) restricted jaw opening, and 4) restricted neck/jaw mobility. Incisor and tongue pounds of force (lbf) were continuously measured.
Results:
As the difficulty setting increased, forces exerted by the students, residents, and staff on the incisors and tongue base increased (p=0.01). Between normal and maximally restricted settings, force delivered to the incisors increased by 6.95 lbf (standard error (SE) 1.29), 5.93 lbf (SE 0.98), and 5.94 lbf (SE 0.70) for the students, residents, and staff, respectively. At the tongue base, force increased by 0.37 lbf (SE 0.18), 0.46 lbf (SE 0.14), and 0.73 lbf (SE 0.15) for the students, residents, and staff, respectively. Esophageal intubations occurred in 50% of the students, 23% of the residents, and 45% of the otolaryngology staff at maximal difficulty, with none at the easiest setting (p=0.33). Compared to the residents, the staff applied significantly increased pressure on the tongue base during laryngoscopy (p=0.02).
Conclusion:
Forces exerted on the incisors and tongue base varied across exposure difficulty and expertise levels, suggesting that they may be useful markers for training and competence assessment.
In the prehospital setting, "to tube, or not to tube" will persist as a probing question - long after this article is published. It is the hope of the authors simply to position a compilation of thoughts to consider in regards to alternate airways vs. endotracheal intubation. Ultimately, it's all about the right care, for the right patient, at the right time!
Background:
Emergency medicine residents are often involved in the management of trauma airways. There are few data on the correlation between prior intubation experience and first-pass trauma intubation success for emergency medicine residents.
Objectives:
We attempted to elucidate a relationship between prior resident intubation experience and first-pass success for trauma patient intubation.
Methods:
We combined two data sets to assess for correlation between prior intubation experience for postgraduate year 2 and 3 residents and first-pass success for trauma patient intubation. Prior intubation experience was gathered from resident procedure logs and trauma intubation data were collected as part of a quality-monitoring program. A univariable logistic regression analysis for all available variables was performed, with first-pass intubation success as the outcome of interest.
Results:
We included 295 consecutive trauma patients intubated at a Level I trauma center where we could link the resident prior intubation experience (total intubations) with intubation attempt quality data. First-pass success for all emergency medicine residents was 82.3% (233/283). Overall successful intubation rate for emergency medicine residents was 90.4% (256/283). The combination of airway management by both the resident and emergency medicine attending provided an overall success rate of 97.3% (287/295). There was no statistically significant association between first-pass success and prior resident intubation experience or any of the other measured variables.
Conclusion:
We did not demonstrate any significant correlation between first-pass intubation success and number of prior intubations performed by the emergency medicine resident.
To determine the minimum number of endotracheal intubation (ETI) attempts necessary for a novice emergency medicine (EM) trainee to become proficient with this procedure. This single-center study retrospectively analyzed data obtained from the institutional airway registry during the period from April 2014 to March 2021. All ETI attempts made by EM trainees starting their residency programs between 2014 and 2018 were evaluated. We used a first attempt success (FAS) rate of 85% as a proxy for ETI proficiency. Generalized linear mixed models were used to evaluate the association between FAS and cumulative ETI experience. The number of ETI attempts required to achieve an FAS rate of ≥ 85% was estimated using the regression coefficients obtained from the model. The study period yielded 2077 ETI cases from a total of 1979 patients. The FAS rate was 78.6% (n = 1632/2077). After adjusting for confounding factors, the cumulative number of ETI cases was associated with increased FAS (adjusted odds ratio, 1.010 per additional ETI case; 95% confidence interval 1.006–1.013; p < 0.001). A minimum of 119 ETI cases were required to establish a ≥ 85% likelihood of FAS. At least 119 ETI cases were required for EM trainees to achieve an FAS rate of ≥ 85% in the emergency department.
This chapter looks at the fundamental skills and objectives of airway management in the context of trauma. While intubation is seen as the gold standard treatment for airway management, there are multiple interventions that can be undertaken before this is required. Intubation may be the wrong course of action occasionally, or beyond the skill set of some providers so the techniques contained within this chapter are core skills which should be achieved by personnel who may be involved in looking after trauma patients. Consideration is given to the underlying thought processes and considerations when deciding on an airway management strategy, as well as the physical symptoms and signs of impending or actual airway obstruction. Potential or actual cervical spine injuries are often cited as cause for concern when moving the neck to establish airway patency, and this chapter also considers the current evidence for and against the potential for movement of the cervical spine to cause injury. Having a mental schema of escalating through interventions which may assist in establishing airway patency is useful, and an “airway ladder” is suggested here. This may cumulate in the establishment of a patent airway via cannula or surgical methods, and this is a skill which should not be restricted to doctors only.
Background
Video laryngoscopy has directly impacted airway management, with numerous studies demonstrating its utility in clinical management of anatomically difficult airways. However, availability of video laryngoscopes in all clinical areas has been limited by the relatively high cost. We used smartphone technology, miniature cameras and three-dimensional printing to design and create an innovative low-cost hyperangulated video laryngoscope. This has the potential to make the technique more widely available. The aim of this study was to determine if time to intubation with the novel device was clinically equivalent to an existing gold-standard video laryngoscope (Storz CMAC with Dörges blade).
Methods
We conducted a randomised, controlled, cross-over equivalence study with 100 skilled practitioners who had previous video laryngoscopy experience. Participants received instruction on the new device, and adequate opportunity to practice. Intubations were then performed in a randomised order on a mannikin simulating a difficult airway. Video recordings of each intubation were analysed by two independent investigators to determine time to intubation. A mean difference in intubation time of less than 10 seconds was determined a priori to denote clinical equivalence.
Results
Mean difference in intubation time between the devices was 4.9 seconds, (two one-sided test 95%CI: 2.3 – 7.5seconds). The innovative low-cost VL was thus clinically equivalent to the industry standard in a simulated difficult airway. Further testing in vivo in a clinical environment is needed.
Conclusion
The results of this study show that a low-cost disposable hyperangulated video laryngoscope is clinically equivalent to the industry standard in a simulated difficult airway. In the context of the current global pandemic, video laryngoscopy has been advised in nearly all airway guidelines. Access to a low-cost VL which does not require reprocessing may be of great value.
Objectives:. To investigate the change in rate of invasive procedures (endotracheal intubation, central venous catheters, arterial catheters, and peripheral inserted central venous catheters) performed in PICUs per admission over time. Secondarily, to investigate the change in type of respiratory support over time.
Design:. Retrospective study of prospectively collected data using the Virtual Pediatric Systems (VPS; LLC, Los Angeles, CA) database.
Setting:. North American PICUs.
Patients:. Patients admitted from January 2009 to December 2017.
Interventions:. None.
Measurements and Main Results:. There were 902,624 admissions from 161 PICUs included in the analysis. Since 2009, there has been a decrease in rate of endotracheal intubations, central venous catheters placed, and arterial catheters placed and an increase in the rate of peripheral inserted central venous catheter insertion per admission over time after controlling for severity of illness and unit level effects. As compared to 2009, the incident rate ratio for 2017 for endotracheal intubation was 0.90 (95% CI, 0.83–0.98; p = 0.017), for central venous line placement 0.69 (0.63–0.74; p < 0.001), for arterial catheter insertion 0.85 (0.79–0.92; p < 0.001), and for peripheral inserted central venous catheter placement 1.14 (1.03–1.26; p = 0.013). Over this time period, in a subgroup with available data, there was a decrease in the rate of invasive mechanical ventilation and an increase in the rate of noninvasive respiratory support (bilevel positive airway pressure/continuous positive airway pressure and high-flow nasal oxygen) per admission.
Conclusions:. Over 9 years across multiple North American PICUs, the rate of endotracheal intubations, central catheter, and arterial catheter insertions per admission has decreased. The use of invasive mechanical ventilation has decreased with an increase in noninvasive respiratory support. These data support efforts to improve exposure to invasive procedures in training and structured systems to evaluate continued competency.
Introducción
La videolaringoscopia es una técnica recomendada para el manejo de la vía aérea; sin embargo, se requiere una medida objetiva como meta de entrenamiento.
Métodos
Estudio descriptivo de curvas CUSUM, con porcentaje de éxito del 80%, error Alfa 0,1, Beta 0,1, con valores de error aceptable de 0,2 y error inaceptable de 0,31.
Resultados
Se crearon curvas CUSUM de 35 estudiantes de posgrado: 23 alcanzaron el mínimo de procedimientos y 13 alcanzaron la meta planteada, con una mediana de 15 procedimientos (RIQ 11-19). La mayoría de los estudiantes que no completaron la curva realizaron solo un mes de rotación.
Conclusión
El uso de curvas CUSUM podría ser de ayuda para individualizar las metas de aprendizaje en habilidad técnica.
Resumen
Introducción
La videolaringoscopia es una técnica recomendada para el manejo de la vía aérea; sin embargo, se requiere una medida objetiva como meta de entrenamiento.
Métodos
Estudio descriptivo de curvas CUSUM, con porcentaje de éxito del 80%, error Alfa 0,1, Beta 0,1, con valores de error aceptable de 0,2 y error inaceptable de 0,31.
Resultados
Se crearon curvas CUSUM de 35 estudiantes de posgrado: 23 alcanzaron el mínimo de procedimientos y 13 alcanzaron la meta planteada, con una mediana de 15 procedimientos (RIQ 11-19). La mayoría de los estudiantes que no completaron la curva realizaron solo un mes de rotación.
Conclusión
El uso de curvas CUSUM podría ser de ayuda para individualizar las metas de aprendizaje en habilidad técnica.
Airway simulators, or training manikins, are frequently used in research studies for device development and training purposes. This study was designed to determine the anatomic accuracy of the most frequently used low‐fidelity airway training manikins. Computerised tomography scans and ruler measurements were taken of the SynDaver®, Laerdal® and AirSim® manikins. These measurements were compared with human computerised tomography (CT) scans (n = 33) from patients at the University of Michigan Medical Center or previously published values. Manikin measurements were scored as a percentile among the distribution of the same measurements in the human population and 10 out of 27 manikin measurements (nine measurements each in three manikins) were outside of two standard deviations from the mean in the participants. All three manikins were visually identifiable as outliers when plotting the first two dimensions from multidimensional scaling. In particular, the airway space between the epiglottis and posterior pharyngeal wall, through which airway devices must pass, was too large in all three manikins. SynDaver, Laerdal and AirSim manikins do not have anatomically correct static dimensions in relation to humans and these inaccuracies may lead to imprecise airway device development, negatively affect training and cause over‐confidence in users.
Objectives:
Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients.
Design:
A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018.
Setting:
Forty-six international PICUs.
Patients:
Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU.
Interventions:
None.
Measurements and main results:
The primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001).
Conclusions:
Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies.
Neonatal intubation is a lifesaving procedure. Neonatal intubation has been an essential skill in the practice of neonatology since the subspecialty was founded in the 1970s; however, the origins of neonatal intubation date back over 200 years. Multiple advances have taken place in the practice of neonatal intubation since it was first described. Continued advances will undoubtedly take place in the future. Although the incidence of neonatal intubation has decreased over time, intubation remains a critical skill for neonatal clinicians. Current and future efforts focused on improving neonatal intubation safety are critical to improving neonatal outcomes. In this review, we examine the past, present, and future of neonatal intubation.
Introduction:
The American Society of Anesthesiologists (ASA) difficult airway algorithm and the Vortex approach are difficult airway aids. Our objective was to demonstrate that a simpler cognitive model would facilitate improved decision-making during a process such as difficult airway management. We hypothesized the simpler Vortex approach would be associated with less anxiety and task load.
Methods:
Medical students were randomized to the ASA algorithm (n = 33) or Vortex approach (n = 34). All learned basic airway techniques on day 1 of their rotation. Next, they watched a video of their respective aid then managed a simulated airway crisis. We assessed decision-making using a seven-point airway management score and a completeness score. Completeness was at least one attempt at each of four techniques (mask ventilation, supraglottic airway, intubation, and cricothyrotomy). Two validated tools, the State-Trait Anxiety Inventory Form Y and the National Aeronautics and Space Administration Task Load Index, were used to assess anxiety and task load.
Results:
Students in the Vortex group had higher airway management scores [4.0 (interquartile range = 4.0 to 5.0) vs. 4.0 (3.0 to 4.0), P = 0.0003] and completeness (94.1% vs. 63.6%, P = 0.003). In the ASA group, the means (SD) of National Aeronautics and Space Administration Task Load Index scores of 55 or higher were observed in mental [61.4 (14.4)], temporal [62.3 (22.9)], and effort [57.1 (15.6)] domains. In the Vortex group, only the temporal load domain was 55 or higher [mean (SD) = 57.8 (25.4)]. There was no difference in anxiety.
Conclusions:
Medical students perform better in a simulated airway crisis after training in the simpler Vortex approach to guide decision-making. Students in the ASA group had task load scores indicative of high cognitive load.
Background
Endotracheal intubation (ETI) is the gold standard for the out-of-hospital emergency airway management in severely injured patients. Due to time-critical circumstances, poor patient presentation and hostile environments, it may be prone for mechanical complications and failure.
Methods
In a retrospective study (January 2011 to December 2013), all patients who underwent out-of-hospital ETI before admittance to a level 1 trauma center were analyzed consecutively. Patients with supraglottic airways, being under cardiopulmonary resuscitation and interfacility transports were excluded. The main study endpoint was the incidence of unrecognized tube malposition; secondary endpoints were Glasgow Outcome Scale (GOS) and in-hospital mortality adjusted to on-scene Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Abbreviated Injury Scale head (AIS head), and on-scene time.
Results
Out of 1176 patients, 151 underwent out-of-hospital ETI. At hospital admission, tube malpositions were recognized in nine patients (5.9%). Accidental and unrecognized esophageal intubation was detected in five patients (3.3%) and bronchial intubation in four patients (2.7%). Although ISS (p=0.053), AIS head (p=0.469), on-scene GCS (p=0.151), on-scene time (p=0.530), GOS (p=0.748) and in-hospital mortality (p=0.431) were similar compared with correctly positioned ETI tubes, three esophageal intubation patients died due to hypoxemic complications.
Discussion
In our study sample, out-of-hospital emergency ETI in severely injured patients was associated with a considerable tube misplacement rate. For safety, increased compliance to consequently use available technologies (eg, capnography, video laryngoscopy) for emergency ETI should be warranted.
Level of evidence
Level of Evidence IIA.
Despite advances in healthcare, maternal morbidity and mortality rates have been rising over the last three decades. Potential contributors to this alarming trend include advances in assisted reproductive technologies allowing women to conceive at older ages than previously possible, an increasing number of pregnancies affected by chronic diseases, a rising cesarean delivery rate resulting in complications such as abnormal placentation, and medical advances allowing women with complex illnesses to conceive. Expert consensus has endorsed simulation over traditional teaching methods for improving learner skill and patient outcomes, particularly in a setting of rarely encountered illnesses and increasingly complex patients. Maternal cardiac arrest simulations are one of the more extensively studied obstetrical critical care scenarios, and participation has been associated with improved learner performance. With such promising data in the setting of growing numbers of obstetrical simulation programs, a logical next step is the incorporation of obstetric critical care scenarios into simulation curricula. This chapter will discuss the use of simulation for teaching critical care obstetrics.
Aim:
The cardiopulmonary resuscitation (CPR) guidelines recommend that endotracheal intubation (ETI) should be performed only by highly skilled rescuers. However, the definition of 'highly skilled' is unclear. This study evaluated how much experience with ETI is required for rescuers to perform successful ETI quickly without complications including serious chest compression interruption (interruption time <10 sec) or oesophageal intubation during CPR.
Methods:
This was a clinical observation study using review of CPR video clips in an urban emergency department (ED) over 2 years. Accumulated ETI experience and performance of ETI were analysed. Main outcomes were 1) 'qualified ETI': successful ETI within 60 sec without complications and 2) 'highly qualified ETI': successful ETI within 30 sec without complications.
Results:
We analysed 110 ETIs using direct laryngoscopy during CPR. The success rate improved and the time to successful ETI decreased with increasing experience; however, the total interruption time of chest compression did not decrease. A 90% success rate for qualified ETI required 137 experiences of ETIs (1,218 days of training). A 90% success rate for highly qualified ETI required at least 243 experiences of ETIs (1,973 days of training).
Conclusions:
Accumulated experience can improve the ETI success rate and time to successful ETI during CPR. Because ETI must be performed quickly without serious interruption of chest compression during CPR, becoming proficient at ETI requires more experience than that required for non-arrest patients. In our analysis, more than 240 experiences were required to achieve a 90% success rate of highly qualified ETI.
Background
The Emergency Medicine (EM) Milestone Project provides guidance for assessment of resident trainee airway management proficiency (PC10). Although milestones provide a general structure for assessment, they do not define performance standards. The objective of this project was to establish comprehensive airway management performance standards for EM trainees at both novice and mastery levels of proficiency.
Methods
Comprehensive airway management standards were derived using standard‐setting procedures. A panel of residency education and airway management experts was convened to determine how trainees would be expected to perform on 51 individual tasks in a standardized airway management simulation encompassing preparation, endotracheal intubation, backup airway use, and ventilation. Experts participated in facilitated exercises in which they were asked to 1) define which items were critical for patient safety, 2) predict the performance of a “novice” learner, and 3) predict the performance of a “mastery” learner nearing independent practice. Experts were given a worksheet to complete and descriptive statistics were calculated using STATA 14.
Results
Experts identified 39 of 51 (76%) airway management items as critical for patient safety. Experts also noted that novice trainees do not need to complete all the items deemed to be critical prior to starting practice since they will be supervised by a board‐certified EM physician. In contrast, mastery‐level trainees would be expected to successfully complete not only the critical tasks, but also nearly all the items in the assessment (49/51, 96%) since they are nearing independent practice.
Conclusion
In this study, we established EM resident performance standards for comprehensive airway management during a simulation scenario. Future work will focus on validating these performance standards in current resident trainees as they move from simulation to actual patient care.
Background:
Hypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room.
Methods:
Multicenter, randomized trial comparing ramped position (head of the bed elevated to 25 degrees) to sniffing position (torso supine, neck flexed, head extended) among 260 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows in four intensive care units between July 22, 2015 and July 19, 2016. The primary outcome was lowest arterial oxygen saturation between induction and two minutes after intubation. Secondary outcomes included Cormack-Lehane grade of glottic view, difficulty of intubation, and number of laryngoscopy attempts.
Results:
The median lowest arterial oxygen saturation was 93% [IQR 84-99%] with ramped position versus 92% [IQR 79-98%] with sniffing position (P = .27). Ramped position appeared to increase the incidence of grade III or IV view (25.4% vs 11.5%, P = .01), increase the incidence of difficult intubation (12.3% vs 4.6%, P = .04), and decrease the rate of intubation on the first attempt (76.2% vs 85.4%, P = .02).
Conclusions:
In this multicenter trial, ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared to sniffing position. Ramped position may worsen glottic view and increase the number of laryngoscopy attempts required for successful intubation.
Background:
The purpose of the study was to use the cumulative summation (CUSUM) test to assess the learning curve during the introduction of a new surgical technique (patient-specific instrumentation) in total knee arthroplasty (TKA) in an academic department.
Methods:
The first 50TKAs operated on at an academic department using patient-specific templates (PSTs) were scheduled to enter the study. All patients had a preoperative computed tomography scan evaluation to plan bone resections. The PSTs were positioned intraoperatively according to the best-fit technique and their three-dimensional orientation was recorded by a navigation system. The position of the femur and tibia PST was compared to the planned position for four items for each component: coronal and sagittal orientation, medial and lateral height of resection. Items were summarized to obtain knee, femur and tibia PST scores, respectively. These scores were plotted according to chronological order and included in a CUSUM analysis. The tested hypothesis was that the PST process for TKA was immediately under control after its introduction.
Results:
CUSUM test showed that positioning of the PST significantly differed from the target throughout the study. There was a significant difference between all scores and the maximal score. No case obtained the maximal score of eight points. The study was interrupted after 20 cases because of this negative evaluation.
Conclusion:
The CUSUM test is effective in monitoring the learning curve when introducing a new surgical procedure. Introducing PST for TKA in an academic department may be associated with a long-lasting learning curve. The study was registered on the clinical.gov website (Identifier NCT02429245).
Cardiac critical care units are high-risk clinical environments. Medical emergencies are frequent and require the intervention of a cohesive, efficient, and well trained interprofessional team. In modern clinical practice there is increased emphasis on safety but also increased lack of acceptance of medical errors and as a consequence, increased litigation. In the past decade, simulation-based learning has arisen as an effective and safe means to learn and practice acute care setting skills. It has been used and studied in different contexts including procedural skills training, crisis resource management and team training, patient and family member communication skills, and health care system quality improvement. Simulation-based education is a relatively recent teaching strategy and evidence of its efficacy continues to grow. Nevertheless, many influential medical societies are now promoting a simulation-based approach for cardiovascular training and continuing medical education. In this article we review the simulation literature in the intensive care unit and evaluate its integration in coronary care units and postoperative cardiovascular intensive care units. We also provide resources for educators and clinicians who wish to implement simulation workshops in these settings.
Cardiac critical care units are high-risk clinical environments. Medical emergencies are frequent and require the intervention of a cohesive, efficient and well-trained interprofessional team. In modern clinical practice there is increased emphasis on safety but also increased lack of acceptance of medical errors and as a consequence, increased litigation. In the past decade, simulation-based learning has arisen as an effective and safe means to learn and practice acute care setting skills. It has been used and studied in different contexts including procedural skills training, crisis resource management and team training, patient and family member communication skills and healthcare system quality improvement. Simulation-based education is a relatively recent teaching strategy and evidence of its efficacy continues to grow. Nevertheless, many influential medical societies are now promoting a simulation-based approach for training and continuing medical education in the cardiovascular field. This article will review the simulation literature in the intensive care unit and will evaluate its integration in Coronary Care Units (CCUs) and postoperative Cardiovascular Intensive Care Units (CVICUs). It will also provide resources for educators and clinicians wishing to implement simulation workshops in these settings.
Introduction:
According to the Accreditation Council for Graduate Medical Education emergency medicine requirements established before the popularity of video laryngoscopy (VL) use, 35 intubations are necessary for graduation. Our study aimed to establish a mastery-learning model for a skill set very different (VL) from direct laryngoscopy and to determine the attempts to achieve mastery with VL.
Methods:
With the use of a randomized, controlled crossover study design, 2 learner groups underwent baseline testing intubating a mannequin using VL. Afterward, the intervention group received mastery training intervention. After training, learners were required to repeat the procedure until achievement of 100% on the checklist for 2 consecutive attempts was achieved. After 3 months, both groups returned for retesting, and the control group received the same mastery training as the intervention group. Both groups returned for final testing after another 3 months.
Results:
The intervention arm had an improvement in performance versus the control arm at 3 months of total time (P < 0.05). Both groups had an improvement within their groups' checklist scores at 3 months after training (P < 0.05), and within the intervention arm, this effect was sustained at 6 months (P < 0.05). There was no significant difference in the mean required attempts to demonstrate mastery (overall, 2.5; intervention, 2.75; control 2.25; P = 0.28).
Conclusions:
Simulation-based mastery-learning produces skill enhancement with VL that is resistant to decay across 6 months. Furthermore, although a small number of attempts are needed to achieve mastery, clinical experience did not substitute as a proxy for skill acquisition. This mastery-learning model provides skill sets that are not otherwise obtained in the clinical curriculum in a 3-month period.
Objective:
To assess clinical measurement competency by two sequential test formulations [resetting sequential probability ratio test (R-SPRT) and learning curve cumulative summation (LC-CUSUM)].
Design:
Numerical simulation and retrospective observational study.
Setting:
Obstetric ultrasound department.
Participants:
Cohorts of 10,000 simulated trainees and 62 obstetric sonographers training in nuchal translucency (NT) measurement at the 11-14-week pregnancy scan with limited case availability.
Intervention:
Application of LC-CUSUM and R-SPRT to clinical measurement training.
Main outcome measures:
Proportions of real trainees achieving competency by LC-CUSUM and R-SPRT, proportions of simulated competent trainees not achieving competency (Type I error), proportions of simulated incompetent trainees achieving competency (Type II error), distribution of case number required to achieve competency (run length) and frequency of resets.
Results:
For simulated cohorts, significant differences in run-length distribution and true test error rates were found between the R-SPRT and LC-CUSUM tests with equivalent parameters. Increasing the cases available to each trainee reduced the Type I error rate but increased the Type II error rate for both sequential tests for all choices of unacceptable failure rate. Discontinuities in the proportion of trainees expected to be test competent were found at critical values of unacceptable failure rate.
Conclusions:
With equivalent parameters, the R-SPRT and LC-CUSUM formulations of sequential tests produced different outcomes, demonstrating that the choice of test method, as well as the choice of parameters, is important in designing a training scheme. The R-SPRT detects incompetence as well as competence and may indicate need for further training. Simulations are valuable in estimating the proportions of trainees expected to be assessed as competent.
Many healthcare professionals are trained in direct laryngoscopic tracheal intubation (LEI), which is a potentially lifesaving procedure. This study attempts to determine the number of successful LEI exposures required during training to assure competent performance, with special emphasis on defining competence itself.
Analyses were based on a longitudinal study of novices under training conditions in the operating room. The progress of 438 LEIs performed by the 20 nonanesthesia trainees was monitored by observation and videotape analysis. Eighteen additional LEIs were performed by experienced anesthesiologists to define the standard. A generalized linear, mixed-modelling approach was used to identify key aspects of effective training and performance. The number of tracheal intubations that the trainees were required to perform before acquiring expertise in LEI was estimated.
Subjects performed between 18 and 35 laryngoscopic intubations. However, statistical modeling indicates that a 90% probability of a "good intubation" required 47 attempts. Proper insertion and lifting of the laryngoscope were crucial to "good" or "competent" performance of LEI. Traditional features, such as proper head and neck positions, were found to be less important under the study conditions.
This study determined that traditional LEI teaching for nonanesthesia personnel using manikin alone is inadequate. A reevaluation of current standards in LEI teaching for nonanesthesia is required.
It has been established that measures and reports of smoking behaviours are subject to substantial measurement errors. Thus, the manifest Markov model which does not consider measurement error in observed responses may not be adequate to mathematically model changes in adolescent smoking behaviour over time. For this purpose we fit several Mixed Markov Latent Class (MMLC) models using data sets from two longitudinal panel studies--the third Waterloo Smoking Prevention study and the UWO smoking study, which have varying numbers of measurements on adolescent smoking behaviour. However, the conventional statistics used for testing goodness of fit of these models do not follow the theoretical chi-square distribution when there is data sparsity. The two data sets analysed had varying degrees of sparsity. This problem can be solved by estimating the proper distribution of fit measures using Monte Carlo bootstrap simulation. In this study, we showed that incorporating response uncertainty in smoking behaviour significantly improved the fit of a single Markov chain model. However, the single chain latent Markov model did not adequately fit the two data sets indicating that the smoking process was heterogeneous with regard to latent Markov chains. It was found that a higher percentage of students (except for never smokers) changed their smoking behaviours over time at the manifest level compared to the latent or true level. The smoking process generally accelerated with time. The students had a tendency to underreport their smoking behaviours while response uncertainty was estimated to be considerably less for the Waterloo smoking study which adopted the 'bogus pipeline' method for reducing measurement error while the UWO study did not. For the two-chain latent mixed Markov models, incorporating a 'stayer' chain to an unrestricted Markov chain led to a significant improvement in model fit for the UWO study only. For both data sets, the assumption for the existence of an independence chain did not lead to significant improvement in model fit. The unrestricted two-chain latent mixed Markov model led to a significant improvement of model fit compared to a simple latent Markov model, but this model was overparameterized when the latent transition probabilities and/or response probabilities were assumed nonstationary. For the other models, the manifest/latent transition probabilities and response probabilities (for the four-wave Waterloo study only) were tested to be nonstationary for both data sets.
Proficiency in endotracheal intubation (ETI) is assumed to improve primarily with accumulated experience on live patients. While the National Standard Paramedic Curriculum recommends that paramedic students (PSs) perform at least five live ETIs, these training opportunities are limited.
To evaluate the effects of cumulative live ETI experience, elapsed duration of training, and clinical setting on PS ETI proficiency.
The authors used longitudinal, multicenter data from 60 paramedic training programs over a two-year period. The PSs reported outcomes (success/failure) for all live ETIs attempted in the operating room (OR), the emergency department (ED), the intensive care unit (ICU), and other hospital or prehospital settings. Fixed-effects logistic regression was used to model up to 30 consecutive ETI efforts by each PS, accounting for per-PS clustering. For each patient, the authors evaluated the association between ETI success and the PS's cumulative number of ETIs, adjusted for clinical setting, elapsed number of days from the first ETI encounter, and the interaction (cumulative ETIs x elapsed days). Predicted probability plots were constructed depicting the "learning curve" overall and for each clinical setting. Results. Between one and 74 ETIs (median 7; IQR 4-12) were performed by each of 802 PSs. Of 7,635 ETIs, 6,464 (87.4%) were successful. Stratified by clinical setting, 6,311 (82.7%) ETIs were performed in the OR, 271 (3.6%) in the ED, 64 (0.8%) in the ICU, 86 (1.1%) in other in-hospital settings, and 903 (11.8%) in the prehospital setting. For the 7,398 ETIs included in the multivariate analysis, cumulative number of ETI was associated with increased adjusted odds of ETI success (odds ratio 1.067 per ETI; 95% CI: 1.044-1.091). ETI learning curves were steepest for the ICU and prehospital settings but lower than for other clinical settings.
Paramedic student ETI success improves with accumulated live experience but appears to vary across different clinical settings. Strategies for PS airway education must consider the volume of live ETIs as well as the clinical settings used for ETI training.
The report of the CUSUM across surgical and interventional procedures has spawned a fair confusion in the literature.
To assess the use of the CUSUM and to clarify its utilisation in the perspective of future studies. Nature of the study: Retrospective review.
A systematic literature search of Medline was carried out. From each article, data regarding the design of the study, the specialty, the performance criterion, the unit under control, the methodology and the model of the CUSUM used, the use of a graph, the use of a test and the type of test applied were retrieved.
31 studies were found relevant. The design was mainly retrospective for the analysis of the learning curve. The main performance criteria under control were morbidity, mortality and success of the procedure. A graph was plotted in all studies as a CUSUM plot or as cumulative sums of non-negative values. A test was used in 17 studies. Mislabelling of the plot and the test, and misuse of control limits were the most commonly reported mistakes.
The CUSUM tool is not yet properly reported in the surgical literature. Therefore, reporting of the CUSUM should be clarified and standardised before its use widens.
In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.
Airway management in the intensive care unit is more problematic than during anaesthesia. In general, critically ill patients have less physiological reserve and complications are more common, both during the initial airway intervention (which includes risks associated with induction of anaesthesia), and later once the airway has been secured. Despite these known risks, those managing the airway of a critically ill patient, particularly out of hours, may be relatively inexperienced. Solutions to these challenging airway problems include: recognition of those patients with a potential airway problem; implementation of a plan to deal with their airway; immediate availability of a difficult airway trolley; use of capnography for every airway intervention and continuously in all ventilator-dependent patients; and appropriate training of all intensive care unit staff including use of simulation.
To describe the methods, success rates, and immediate complications of tracheal intubations performed in the emergency department of an urban teaching hospital.
This was an observational, consecutive series undertaken in an urban university hospital with an emergency medicine residency training program and an annual ED census of 60,000 patients. The study population included all patients for whom intubation was attempted in the ED during a 1-year period (July 1, 1995 through June 30, 1996). At the time of each intubation, the intubator filled out an intubation data collection form. If an intubation was performed in the ED but no form was filled out, the data were obtained from the medical record.
A total of 610 patients required airway control in the ED; 569 (93%) were intubated by emergency medicine residents or attending physicians. Rapid-sequence intubation (RSI) was used in 515 (84%). A total of 603 patients (98.9%) were successfully intubated; 7 patients could not be intubated and underwent cricothyrotomy. In 33 patients, inadvertent placement into the esophagus occurred; all such situations were rapidly recognized and corrected. Eight (24%) of the 33 esophageal intubations resulted in a reported immediate complication. Overall, 49 patients (8.0%; 95% confidence interval [CI], 6% to 11%) experienced a total of 57 immediate complications (9.3%; 95% CI, 7% to 12%). Three patients sustained a cardiac arrest after intubation; two of these patients had agonal rhythms before intubation, and one probably had a succinylcholine-induced hyperkalemic cardiac arrest.
At this institution, the majority of ED intubations were performed by emergency physicians and RSI was the most common method used. Emergency physicians intubated critically ill and injured ED patients with a very high success rate and a low rate of serious complications.
Introduction:
Cumulative sum (CUSUM) analysis is used to assess competency in practical procedures. Previous studies have used CUSUM to assess competence in administering labour epidural, but these assessments were mainly performed with novice trainees. Different acceptable failure rates for the same procedure, such as administering labour epidural, have been used. In this article, we describe our experience of using CUSUM for the continuing assessment of competence among experienced trainees. We also tested the hypothesis that setting different failure rates can lead to different conclusions about a trainee's competency.
Methods:
After obtaining departmental approval, we collected the records of the first 50 labour epidurals performed by trainees at specialty training (ST) 3/4 level, and plotted two CUSUM graphs for each trainee. For the first CUSUM graph, we used 10 and 20 per cent as acceptable and unacceptable failure rates, respectively. In the second CUSUM graph, we used 15 and 30 per cent as acceptable and unacceptable failure rates, respectively.
Results:
We analysed the CUSUM data of six trainees. With 10 and 20 per cent as acceptable and unacceptable failure rates, only four trainees demonstrated competence. The median number of attempts required was 25, with a range of 25-32 attempts. However, with 15 and 30 per cent used as the acceptable and unacceptable failure rates, five out of six trainees demonstrated competence, with a median of 18 and range of 14-33 attempts.
Discussion:
Our study shows that CUSUM analysis can be successfully used for the continued assessment of competence in experienced trainees. It also shows that setting different failure rates can produce different results, leading to confusion and inconsistency when comparing CUSUM results. With the increasing use of CUSUM analysis, we believe that the organisations responsible for training, such as the Royal College of Anaesthetists, should provide guidance on what is an acceptable failure rate for different procedures, such as the administration of an epidural during labour, at different stages of training.
We sought to determine the learning curve (LC) for fetoscopic laser photocoagulation (FLP) as a model for the evaluation of training in surgical procedures.
A retrospective review of consecutive case series of FLP from 2 centers with 3 operators (operator I [O-I], observer trained; operator II [O-II], hands-on trained; and operator III [O-III], clinical fellow) was performed and the LC-cumulative summation (CUSUM) test was plotted.
The acceptable and unacceptable success rates for at least 1 fetus survival after FLP were set at 82% and 70%, respectively, from a systematic review. A total of 171 consecutive cases were performed by the 3 operators (O-I, 91; O-II, 49; and O-III, 31). From LC-CUSUM test O-I needed 60 procedures, O-II needed 20 procedures, and O-III needed 20 procedures to reach an acceptable performance rate for at least 1 survivor.
The LC-CUSUM test can be used to accurately assess the LC in a surgical procedure in obstetrics and gynecology. Hands-on trained operators exhibit a shorter LC.
The cumulative summation (CUSUM) test is increasingly being used in medicine to monitor a wide variety of processes such as cardiac surgery or disease outbreaks. The CUSUM sequentially tests the null hypothesis that the process is in control, i.e. its mean is equal to a given target. Thus, it detects when the process changes to an out of control state. Conversely, monitoring the learning curve requires detecting the time when the process reaches an in control state. In this work we develop an alternative to the CUSUM, the learning curve CUSUM (LC-CUSUM), that serves to detect when a process deviates from an out of control state to an in control state. The test is based on a two one-sided tests procedure where the null hypothesis is that the process is out of control. This can be written as H(0): |mu-mu(0)|> or =delta tested against H(1): |mu-mu(0)|< delta. The null hypothesis is thus the union of two one-sided hypotheses and is rejected when both are rejected. A CUSUM test statistic is then constructed for each hypothesis in a traditional way. The properties of the test are investigated through numerical simulations, and are illustrated on the learning curve of an endoscopist performing endoscopic retrograde cholangiopancreatographies for biliary tract disorders.
Embryo transfer, a crucial step for achieving pregnancy after in vitro fertilization, is an operator-dependent technique but the number of procedures required for a trainee to reach proficiency is unknown. We set out to evaluate the learning curve (LC) of embryo transfer using a specifically designed statistical tool.
The first embryo transfers performed by five trainees were monitored by the cumulative summation test for learning curve (LC-CUSUM), a statistical tool designed to indicate when a process has reached a predefined level of performance. The main outcome measure was a positive hCG test. A 40% pregnancy rate (PR) per transfer was chosen to define adequate performance and a PR of 20% was considered inadequate. After the learning phase, standard CUSUM were implemented to ensure that performance was maintained. The same CUSUM parameters were also applied to monitor 241 consecutive embryo transfers performed by a senior gynaecologist.
Between 11 and 99 embryo transfers were necessary for the trainees to reach the predefined level of performance. Simple and intuitive graphical representations of the LCs were generated. CUSUM tests confirmed that performance was maintained after the learning phase. The PR of the senior gynaecologist was 42.7% and the CUSUM showed that performance remained adequate throughout the 241 procedures.
This study provides an exportable model for a quantitative monitoring of the LC of embryo transfer as well as a reference curve for continuous monitoring of performance in embryo transfer. The length of the LC of embryo transfer is highly variable, justifying a tailored training to learn this procedure.
Inadequate surgical implantation of a hip replacement may result in decreased patient satisfaction and reduced implant survival. The objective was to monitor surgical performance in hip replacement.
The study took place at a teaching centre. All primary total hip replacements were prospectively included in the series. For each hip replacement, intraoperative technical errors, cup and stem fixation and position, and postoperative complications were recorded. If all items rated were correct, the procedure was considered as correct. The Cumulative Sums (CUSUM) test was used to monitor the performance of the centre. A 90% proportion of successful procedures was considered as adequate performance and a 75% proportion of successful procedures was deemed as inadequate performance. Meetings were conducted to discuss the results of monitoring.
Eighty-three total hip replacements were monitored. Overall, 28 procedures (34%) were considered inadequate. The most potent reasons for inadequate performance were cup positioning and stem fixation. The CUSUM test signalled after the second procedure that performance was inadequate. After the first meeting, despite an improvement was seen, the CUSUM test raised an alarm indicating inadequate performance. The study was stopped after the second meeting because of funding reasons before it could be demonstrated that performance had reached the desired level.
This study has demonstrated that implementing a dedicated system to monitor surgical performance in a teaching hospital improves the quality of implantation of total hip replacements. Nonetheless, the target of ninety percent of adequate primary total hip replacement could not be reached and efforts should be continued.
Unlabelled:
The learning process is a multidimensional function with a wide intra- and interindividual scattering. To determine the learning process in anesthesia, we evaluated 11 first-year residents according to their rate of success or failure when applying manual anesthesiological skills, such as performance of spinal, epidural, or brachial plexus anesthesia and tracheal intubation or insertion of an arterial line. Epidural anesthesia was the most difficult procedure (P < 0.05). Significant differences were found between epidural anesthesia and tracheal intubation (P < 0.05), insertion of an arterial line (P < 0.05), and brachial plexus block (P < 0.05), as well as between spinal anesthesia and orotracheal intubation (P < 0.05). Learning curves are a valid tool for monitoring institutional and individual success.
Implications:
To investigate the learning process in anesthesia, typical anesthetic procedures were performed by inexperienced residents during their first year. Learning curves were generated for each procedure performed. Epidural anesthesia was the most difficult procedure to perform (P < 0.05).
Unlabelled:
This study aimed at constructing learning curves for basic procedural skills in anesthesiology using the cumulative sum method. We recorded 1234 peripheral venous cannulations, 895 orotracheal intubations, 688 spinals, and 344 epidurals performed by residents during the first 10 mo of training. Learning curves for each procedure were constructed by using the cusum method. The number of procedures performed until attainment of acceptable failure rates was calculated. All residents mastered peripheral venous cannulation after 79 +/- 47 procedures. Four of 7 residents attained acceptable failure rates at orotracheal intubation after 43 +/- 33 proce- dures. Seven of 11 residents attained acceptable failure rates at spinal anesthesia after 36 +/- 20 procedures. At epidural anesthesia, 5 of 11 residents attained acceptable failure rates after 21 +/- 11 procedures. The cusum method is a useful tool for objectively measuring performance during the learning phase of basic procedures. The wide interindividual variability in the number of procedures required to be performed before attaining acceptable failure rates suggests that performance should be followed on an individual basis.
Implications:
Learning curves for peripheral venous cannulation, tracheal intubation, and spinal and epidural anesthesia were constructed using the cumulative sum (cusum) method. There was a wide variability in the number of procedures performed until attainment of acceptable failure rates. The cusum method may improve our means of evaluating residents' technical skills.
In this paper we discuss the use of charts derived from the sequential probability ratio test (SPRT): the cumulative sum (CUSUM) chart, RSPRT (resetting SPRT), and FIR (fast initial response) CUSUM. The theoretical development of the methods is described and some considerations one might address when designing a chart, explored, including the approximation of average run lengths (ARLs), the importance of detecting improvements in a process as well as detecting deterioration and estimation of the process parameter following a signal.
Two examples are used to demonstrate the practical issues of quality control in the medical setting, the first a running example and the second a fully worked example at the end of the paper. The first example relates to 30-day mortality for patients of a single cardiac surgeon over the period 1994-1998, the second to patient deaths in the practice of a single GP, Harold Shipman.
The charts’ performances relative to each other are shown to be sensitive to the definition of the ‘out of control’ state of the process being monitored. In light of this, it is stressed that a suitable means by which to compare charts is chosen in any specific application.
Current methods available for assessing the learning curve, such as a predefined number of procedures or direct observation by a tutor, are unsatisfactory. A new tool, the cumulative summation test for learning curve (LC-CUSUM), has been developed that allows quantitative and individual assessment of the learning curve.
Some 532 endoscopic retrograde cholangiopancreatographies (ERCPs) performed by one endoscopist over 8 years were analysed retrospectively using LC-CUSUM to assess the learning curve. The procedure was new to the endoscopist and monitored prospectively in the initial study. Success of the procedure was defined as cannulation and proper visualization of the duct(s) selected before the examination.
Fifty ERCPs were considered unsuccessful. There was a gradual improvement in performance over time from a success rate of 82.0 per cent for the first 100 procedures to 96.1 per cent for the last 129 procedures. The LC-CUSUM signalled at the 79th procedure, indicating that sufficient evidence had accumulated to prove that the endoscopist was competent.
LC-CUSUM allows quantitative monitoring of individual performance during the learning process.
Training time and consultant practice Education in airway management
- Jd Greaves
- Pa Baker
- Jm Weller
- Kb Greenland
Greaves JD. Training time and consultant practice. Br J Anaesth 2005;95:581–3.
15 Baker PA, Weller JM, Greenland KB, et al. Education in airway management.
Anaesthesia 2011;66:101–11.
Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures?
- Konrad