Hello, my name is Mark Weber. I'm a nurse practitioner in the Pediatric Intensive Care Unit at the Children's Hospital of Philadelphia. My role within the PICU is the program manager for vascular access initiatives. And today we'll be talking about who should perform procedures in the ICU, a dedicated procedure team, or a clinician who knows the patient. Here are the objectives I will cover as it pertains to the pro-proceduralist perspective. My goal is that I can provide you with sufficient information to allow you to see the benefits of a procedure team working in tandem with the critical care team. Many of the terms I'll use in this talk fall on a bit of a spectrum. So procedural team can be comprised of a registered nurse, an advanced practice provider or physician, and they focus on specific tasks. For this talk, we'll define a procedure team as a focus group of trained providers. Now the difference between knowing the patient and not knowing the patient can fall on a spectrum as well. You can know the patient from a general sense, or you can know the patient on a specific sense. And we'll get into more details about this as we progress. Level of experience can also be on a spectrum. Those on a procedural team may not actually be experienced. And lastly, we see competence, and we know that competence tends to grow with time and experience. So we'll start by looking at the literature and seeing what is out there in terms of procedural teams. We have a nice systematic review that addresses this specific question for us. From a general sense, the data from this review seems promising. Procedural teams can offer experience knowledge on many aspects within their domain of expertise. That's insertion techniques, clinical care, or the management of devices. As we can see, several studies were reviewed, but there were no high-level RCTs found that provided the specific answer to this question. So what does that mean? Is that the end of the story? Do I just walk away now? Let's dive a little bit deeper into some of these studies to see what we can glean from them. So the first study we'll take a look at is a review that describes a vascular access team where advanced practice nurses were responsible for inserting catheters. They provided follow-up clinical support and ongoing hospital-wide educational activities. When we take a look at their outcomes, we can see with temporary central venous catheters that their complication rates were quite low for some of the major complications, such as arterial puncture, chemothorax, pneumothorax, and CLABSI. Similarly, their outcome for PICS were also quite low, low rates of arterial puncture and low rates of CLABSIs. There are two big outcomes that they saw from this study. The first one was that there was a significant offloading of the critical care teams. When this procedural team was able to perform the procedure, that allowed more time for the critical care team to do other tasks within the unit. They also noted that with increased procedural competency occurred over time. We see this is borne out in the literature with other types of procedures, their surgical outcomes with ovarian cancer, CABG, or mitral valve repair. The second study that was found in the Cochrane review was a trial of newly created VAST team, which was formed from nurses that were from the emergency department, the intensive care unit, and the oncology ward. And they provided hospital-wide coverage for IV placement. As with their first study, we see that procedural success and competency improves with time. Here is a chart of their first success with peripheral IV insertions. We know procedural teams may not all start with experts, but they will definitely grow them over time. For their major results, they were able to provide adherence evidence-based practice as it referred to things such as catheter sizing, site rotation, catheter siting, lots of details about catheter management strategies. They also saw a reduction in resident hours that were allotted to placing PIVs and managing these catheters. This allowed those physicians to focus on other aspects of patient care and have less time on catheter management. Procedural teams are not only isolated to just vascular access practices. In this study here, we have an example of a bronchoscopy service that was created to provide airway clearance for intensive care unit patients. This study took place in Australia and was comprised of physiotherapists who were kind of a combination between a respiratory therapist and a physical therapist. Some of the bronchs were done in tandem with the intensivist. The requirements for the physiotherapist were those who were selected based on strong clinical experience and extensive clinical background, roughly 10 years of experience or more. There was a lot of time spent setting up this program. An extended scope of practice was organized for the physiotherapist and their institution. We could see that thorough pre-planning on the front end allowed for the success of this program on the back end. Requirements for bronchoscopy are simple and do not include patients with very increased acuity. Patients with increased acuity required supervision from an ICU specialist. Through this study, patients had improved access to care. There are no major complications. And again, we see this reoccurring theme of offloading the providers so they could have more time spent on other aspects of patient care. Additionally, the physiotherapists were able to train some of the junior medical staff on how to perform simple bronchoscopies. Our next study is a physician-run bronchoscopy service that was on call for emergent cases and for off-hours use. When we look at the benefits to the patients, all the bronchoscopists were asked, following their procedure, of how necessary it was. About 20% of the procedures were deemed not really helpful to the patient, but that leaves about 80% of these procedures that were deemed helpful to the patient. And some of them, up to 20 of them, were even deemed life-saving for these patients. Aside from data on procedural teams, we can look strictly at procedural data that shows us that experience matters, and this leads to improved success and decreased patient harm. Here we have an eight-month review of subclavian line placements at a teaching institution. And we see that those providers with little experience had more complications than those that had more experience. Here we have another study that compares three different approaches for central line placement, looking at subclavian, anterior jugular, or posterior jugular approaches. In this study, experienced providers were defined as those who performed greater than 50 procedures, and a failed attempt was a procedure that required three to five punctures. When we looked at the experienced providers, the failure rate was about 10% and complications of 5%. The inexperienced providers, on the other hand, had almost double the rates of failure, close to 20%, and double the rates of complications at 11%. Our last study, looking at procedures, compares the static use of ultrasound versus a landmark technique for subclavian placement. In this study, complications were defined as catheter misplacement, arterial puncture, pneumothorax, or mediastinal hematoma. We see in this study that the number of needle passes correlated with complications. So patients that required more than two needle sticks had an increase in the percent of complications from 4% up to 24%. Also we see that the failure rate was three times higher for new providers compared to those who are experienced. Now let's kind of synthesize the data thus far. So we see that procedural skills improve over time. Experience leads to decreased complications. Procedural teams can help offload the primary team, allowing them to provide other aspects of patient care. And improved access to timely care can be provided by procedural teams. It's also important to note that the increased competency and skill set also applies to the primary care teams as well who are performing these procedures. It's not just isolated to the procedural teams. Patients in the intensive care unit are at greater risk when the medical and nursing teams are overloaded. We know that workload is quite high. In many of these situations of high workload, there's an increased risk of iatrogenic complications, human error, there's delayed weaning from mechanical ventilations, there's increased risk of hospital-acquired infections. We also know that critical care providers are required to make many decisions based on a large amount of data from multiple assessments and opinions from physicians and non-physicians alike. All this data has to be analyzed in an efficient manner. This is not news to us. We live this all the time. There's a lot on our plate within the ICU. We could take a look into the mind of our intensivist and see there's a lot of data to process. This can be very overwhelming for critical care providers. So the offloading that procedural teams can provide can be highly beneficial. Within the airline industry, the concept of a sterile cockpit was developed because factors contributing to human error, such as stress, distractions, were identified as playing a role in crash investigations. During takeoff and landings, a detailed checklist is used and only conversation related to these activities is allowed. Distractions are minimized and roles are well-defined. We know that we will make errors as humans, and we need to prevent these errors from leading to patient harm. Within the airline industry, there's four ways that are known to mitigate risk. Keeping a particular action, behavior, or task at a minimum, such as minimizing procedures, can help minimize risk. A procedural team can help select appropriate access for a patient to minimize the number of lines that are required. Risk avoidance simply entails limiting or not participating in activities that could lead to a particular or potential occurrence. Where possible, it's the best method to mitigate risk. And it might be best not to do a procedure at all. Another way we can mitigate risk is to transfer that risk to another or more capable party, such as a procedural team. And lastly, distributing hazards to other locations is another way to minimize risk. Some of these procedures can be then offset onto a procedural team to do the work for us. Now, the question always comes up as to, who knows the patient best? The primary team may have a good sense of the comprehensive plan of care and the nuances of the patient, where I propose that a procedural team knows the patient better from the vascular access standpoint. They may know their history from a vascular access perspective, and they have knowledge on device selection. These are all important factors that can help minimize risk when placing lines in patients. There are many factors that go into a pre-procedural assessment, and these are all geared at minimizing risk. A procedural team is comfortable and familiar with performing these assessments, and generally has a bandwidth and time to be able to perform these pre-procedural assessments well. Lastly, it's important to take time with the families to establish trust as a new care team member. The procedural team may be a new face, and it may be hard for the family to accept a new person coming in, asking to do an invasive procedure on their family member. As you know, during the time of COVID, there's a lot of family separation that occurs within the ICU. The procedural team may have more time to go over the details of the risks and benefits than the primary team may have, and this can be valuable in a time when these patient-family interactions are limited. Early in the presentation, I started with these words. We talked about their definitions and shared the extremes of these definitions. I propose that we shouldn't look at these as extremes, but can look at them in a holistic fashion. When we look at the procedural team, instead of looking at those extremes, I propose that we should look at it on a continuum. In conclusion, procedural teams can be integrated with the primary team in meeting the needs of the patient. They have the experience to tease out the details that are important and necessary to perform the procedure safely. Their experience develops with time as they perform more and more of these specific procedures. And lastly, with experience, competency and expert practice is achieved, leading to decreased risks and harm to the patient.

procedural team

critical care teams

patient outcomes

timely care

minimize risks