Dataset Information

Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.

ABSTRACT: To prevent transmission of severe acute respiratory syndrome coronavirus 2 to healthcare workers, we must quickly implement workflow modifications in the pediatric intensive care unit (PICU). Our objective was to rapidly train interdisciplinary PICU teams to safely perform endotracheal intubations in children with suspected or confirmed coronavirus disease 2019 using a structured simulation education program.

Methods

We conducted a quality improvement study in a tertiary referral PICU. After developing stakeholder-driven guidelines for modified intubation in this population, we implemented a structured simulation program to train PICU physicians, nurses, and respiratory therapists. We directly observed PICU teams' adherence to the modified intubation process before and after simulation sessions and compared participants' confidence using the Simulation Effectiveness Tool-Modified (SET-M, Likert scale range 0: do not agree to 2: strongly agree regarding statements of confidence).

Results

Fifty unique PICU staff members participated in 9 simulation sessions. Observed intubation performance improved, with teams executing a mean of 7.3-8.4 out of 9 recommended practices between simulation attempts (P = 0.024). Before undergoing simulation, PICU staff indicated that overall they did not feel prepared to intubate patients with suspected or confirmed SARS-CoV-2 (mean SET-M score 0.9). After the simulation program, PICU staff confidence improved (mean SET-M score increased from 0.9 to 2, P < 0.001).

Conclusion

PICU teams' performance and confidence in safely executing a modified endotracheal intubation process for children with suspected or confirmed SARS-CoV-2 infection improved using a rapidly deployed structured simulation education program.

SUBMITTER: Balikai SC

PROVIDER: S-EPMC7774993 | biostudies-literature | 2021 Jan-Feb

REPOSITORIES: biostudies-literature

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Publications

Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.

Balikai Shilpa C SC Badheka Aditya A Casey Andrea A Endahl Eric E Erdahl Jennifer J Fayram Lindsay L Houston Amanda A Levett Paula P Seigel Howard H Vijayakumar Niranjan N Cifra Christina L CL

Pediatric quality & safety 20201228 1

To prevent transmission of severe acute respiratory syndrome coronavirus 2 to healthcare workers, we must quickly implement workflow modifications in the pediatric intensive care unit (PICU). Our objective was to rapidly train interdisciplinary PICU teams to safely perform endotracheal intubations in children with suspected or confirmed coronavirus disease 2019 using a structured simulation education program.<h4>Methods</h4>We conducted a quality improvement study in a tertiary referral PICU. Af ...[more]

PMID: 33403319

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Project description:BackgroundFor patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure.Research questionFor patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic?Study design and methodsWe conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables.ResultsOne thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01).InterpretationVideo laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.

Project description:Objective: In emergency medicine, airway management is a core skill that includes endotracheal intubation (ETI), a common technique that can result in ineffective ventilation and laryngotracheal injury if executed incorrectly. We present a method for automatically generating performance feedback during ETI simulator training, potentially augmenting training outcomes on robotic simulators. Method: Electret microphones recorded ultrasonic echoes pulsed through the complex geometry of a simulated airway during ETI performed on a full-size patient simulator. As the endotracheal tube is inserted deeper and the cuff is inflated, the resulting changes in geometry are reflected in the recorded signal. We trained machine learning models to classify 240 intubations distributed equally between six conditions: three insertion depths and two cuff inflation states. The best performing models were cross validated in a leave-one-subject-out scheme. Results: Best performance was achieved by transfer learning with a convolutional neural network pre-trained for sound classification, reaching global accuracy above 98% on 1-second-long audio test samples. A support vector machine trained on different features achieved a median accuracy of 85% on the full label set and 97% on a reduced label set of tube depth only. Significance: This proof-of-concept study demonstrates a method of measuring qualitative performance criteria during simulated ETI in a relatively simple way that does not damage ecological validity of the simulated anatomy. As traditional sonar is hampered by geometrical complexity compounded by the introduced equipment in ETI, the accuracy of machine learning methods in this confined design space enables application in other invasive procedures. By enabling better interaction between the human user and the robotic simulator, this approach could improve training experiences and outcomes in medical simulation for ETI as well as many other invasive clinical procedures.

Project description:The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Dataset Information

Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.

Methods

Results

Conclusion

Publications

Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.

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