SCCM Resource Library-23-Translational Simulation Improves Compliance With the NEAR4KIDS Airway Bundle Checklist

Video Transcription

Good evening, my name is Dr. Jordan Newman and I'm a current third year Pediatric Critical Care Medicine Fellow at Emory University School of Medicine and Children's Health Care of  Atlanta. Today I will be talking to you about my project, Translational Simulation Improves Compliance with the Near for Kids Airway Bundle Checklist and a Single Center PICU.  The Near for Kids project and Dr. Akira Nishizaki are supported by the Agency for Healthcare Research and Quality.  Tracheal intubation adverse events occur in approximately 20% of intubations and are associated  with increased length of mechanical ventilation, hospital length of stay, and mortality. Near for Kids, the National Emergency Airway Registry for Children, is a multi-center airway  collaborative whose primary goal is to improve advanced airway management in critically ill children.  In prior studies, we know that clinician, patient, practice factors, and poor team performance as well as ineffective communication all contribute to adverse events.  Therefore, Near for Kids created an Airway Safety Quality Improvement Checklist or bundle, which was a QI tool to improve intubations through standardization of practice, clinical  decision support, and enhanced teamwork and communication. However, compliance with any bundle is difficult and this is not unique to the Near for Kids bundle.  Prior published data by Near for Kids mentions competing QI initiatives, inadequate buy-in,  time barriers, lack of multidisciplinary involvement, and ineffective integration into the local work system, all as barriers to bundle compliance.  However, we also know that there can be latent safety issues within the work environment that act as barriers to compliance that may go unnoticed or unaddressed, and this is where  translational simulation comes into play. Translational simulation is a newly described concept that helps to improve patient care  by identifying safety and performance gaps and delivering simulation-based intervention. By having participants perform activities as done in situ, you're able to uncover latent  safety threats that may otherwise go unnoted and prevent compliance with best practice. This provides a platform for iterative process improvement both during simulation and during  debriefs and then you are able to embed these solutions into ongoing simulation. In our institution, our compliance with the Near for Kids airway bundle was well below  goal and therefore we sought to utilize translational simulation methodologies to uncover barriers  to our compliance and improve our baseline compliance of 66% to greater than 80% to meet that of the Near for Kids target.  In total, we had 180 learners participate in simulation sessions. These included critical care medicine fellows, advanced practitioners, nurses, and respiratory therapists.  We conducted a total of 41 days of simulation over 10 months with each session totaling around three hours.  To hardwire the correct and complete utilization of the Near for Kids airway bundle checklist, we delivered simulation using rapid cycle deliberate practice methodologies.  This provides just-in-time feedback and targeted coaching to learners, involves frequent pauses for feedback based on predetermined stops, particularly in this case, the checklist,  and requires learners to repeat skills until they are mastered. The sessions concluded with traditional reflective debriefing that allowed discussions to unmask  latent safety barriers that prevented airway bundle compliance during the simulations. Translational simulation encompasses three elements, exploration, testing, and embedding.  Through exploration and testing, learners actively engage in the intubation process and effectively unmask process limitations, elucidating the rationale for poor adherence  to the bundle from the clinician's perspective. As simulation elucidated how the bundle did not fit into the current intubation workflow,  iterative changes were adopted and embedded into further training to increase the simulation-based intervention's reliability.  This is a p-chart demonstrating improvement in bundle adherence. The y-axis shows percent compliance with the airway bundle checklist, and the x-axis reflects time.  The solid green line is our average percentage monthly bundle compliance, and the solid red line demonstrates our goal of 80%.  As you can see, after our intervention period, we improved our compliance to greater than 90%, well above our goal of 80%.  Additionally, we were able to maintain greater than 90% average compliance 19 months following  our intervention without any additional refresher training, education, or interventions. And this includes adjusting for our ICU's annual turnover of 30 to 40% of nurses and  25% of respiratory therapists. This sustained improvement is unlikely related to simulation-based education alone, and translational  simulation did more than just educate our teams on better practice, rather it engaged teams to explore barriers to compliance and develop lasting solutions that worked for  our unit's workflow. Obviously, through a simulation, we were able to uncover several barriers to compliance  across our intubation process, from the system and our unit's cultural practices, to process and work environment barriers.  To focus on just a few examples, we had an unclear role of a second physician during the intubation process, therefore, we assigned a second non-intubating physician as team  leader to ensure that the checklist was fully completed with each intubation. Second, and very basically, was that we had inconsistent placement of the bundle checklist  within the patient's room, which made it difficult to locate during intubations, particularly  those that were emergent or unplanned, therefore, we standardized the checklist of the location in each patient's room for easy access.  And lastly, we had inconsistent availability of nasal cannula for apneic oxygenation, a critical part of the airway bundle.  So we now store nasal cannula in the nursing bedside cart so it would be easily accessible by any member of the care team, not just the respiratory therapist.  It also allowed nursing staff to empirically begin oxygen delivery prior to the intubation process ever being initiated.  Now, while these examples are unique to our institution, they really reflect the utility of translational simulation and unmasking unrecognized barriers to compliance and patient  safety, and then immediately delivering solutions to those problems that can be hardwired through simulation.  The problem with traditional simulation education is that of skill decay. Compliance inevitably drops without ongoing refreshers, and this has been demonstrated in multiple studies.  The reason we were able to sustain compliance for 19 months without refreshers of any sort is that we addressed the issues within the system.  We identified that many barriers preventing our bundle compliance existed in our work system level barriers, and a lack of knowledge was not the problem, and education alone was  not a reliable intervention as a means to impact best practice and patient safety. We had to address the system as a whole and not just human behavior.  We were able to sustain compliance because we customized the bundle and its use to fit into our unit's particular workflow.  Through simultaneous multidisciplinary engagement, we enhanced the ability of different team  members to anticipate one another's needs and to also anticipate patients' needs surrounding intubation.  This has transformed our safety culture by truly integrating risk assessment and plan development into our workflow and has impacted patient care delivery in a way that we feel  extends beyond intubation as staff apply the tools they learn through translational simulation into different clinical situations.  In summary, how you imagine best practice bundles are being used is unlikely to be how they're used in practice.  Bundle compliance relies on integrating practice into the local microsystem, workflow, and culture.  Translational simulation better demonstrated work is done, bringing clarity to human behavior, perception, and unit-based culture.  It improved adherence to best practice by overcoming barriers through iterative process improvements.  This is an approach that can be used in QI endeavors, new system processes, or best practice  behaviors that are difficult to initiate or sustain, and it can be used in a wide variety of clinical contexts.  Translational simulation allowed us to identify barriers, develop solutions, and integrate those solutions into our workflow in a simulation-based practice.  I would like to thank my mentors, Drs. Nora Coleman and Dr. Kiran Habbar, as well as Dr. Akira Nishisaki for their support and encouragement.  I would also like to thank Melinda Register and Scott Gillespie for their invaluable support  with data collection and data interpretation, as well as all the respiratory, nursing, and physician staff at Children's Health Care of Atlanta, without whom this project would  not have been possible. Again, my name is Jordan Newman, and thank you so much for your time.

Video Summary

Dr. Jordan Newman discusses the use of translational simulation to improve compliance with the Near for Kids airway bundle checklist in a pediatric intensive care unit. The airway bundle checklist aims to improve intubation practices through standardization, decision support, and enhanced teamwork and communication. However, compliance with the checklist was low at their institution. By utilizing translational simulation, they were able to identify barriers to compliance, develop solutions, and integrate them into their workflow. This resulted in significant improvement in compliance, which was sustained even after 19 months without additional interventions. Translational simulation can be a useful tool in improving adherence to best practices in various clinical settings.

Asset Subtitle

Pediatrics, Professional Development and Education, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Jordan W. Newman

Introduction/Hypothesis: The NEAR4KIDS Airway Bundle Checklist is a quality improvement tool that aims to improve the safety of TI. However many barriers to bundle adherence exist. Simulation-based educational interventions have successfully improved compliance with safety bundles and reduced errors. We utilized a translational simulation approach to identify and remediate barriers that contributed to poor compliance. We hypothesized that a simulation-based educational intervention aimed at the integration of the QI bundle checklist at the bedside would be associated with an increased use of the checklist and a decrease in tracheal intubation associated events.

Methods: This was a single-center retrospective review following multi-disciplinary translation simulations aimed at improving compliance with the NEAR4KIDS Airway Bundle Checklist. Primary outcomes were defined as adherence to a QI bundle checklist: compliance and utilization of apneic oxygenation during tracheal intubations. The secondary outcome was the occurrence of adverse tracheal intubation associated events.

Results: Overall 180 learners including 19 pediatric critical care medicine (PCCM) fellows, 4 critical care nurse practitioners, 127 nurses, and 30 respiratory therapists participated in simulations. Compliance with the QI bundle checklist and rates of TIAEs were collected for 12 months prior to simulation and 9 months following simulation. A total of 244 TIs pre-intervention and 158 post-intervention were collected. Adherence to the QI bundle checklist was 66% before simulation and 93.7% post-intervention (p < 0.001). Six months into the intervention and significant month to month to month change were noted. Adherence to apneic oxygenation was 27.9% prior to simulation and 77.9% post-intervention (p < 0.001). There was no difference in the occurrence of any tracheal intubation associated events.

Conclusions: Translational simulation was used as a safety tool used to improve NEAR4KIDS QI bundle checklist compliance and elucidate factors that contributed to successful implementation. Through simulation, we optimized bundle customization through process improvement, fostered a culture of safety, and effectively engaged multidisciplinary teams in this quality initiative as a means to improve adherence to best practice surrounding tracheal intubations.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Professional Development and Education

Knowledge Level Advanced

Membership Level Select

Tag Simulation

Tag Healthcare Delivery

Year 2021

Keywords

translational simulation

compliance

Near for Kids

airway bundle checklist

pediatric intensive care unit

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