619178
research-article2015
AORXXX10.1177/0003489415619178Annals of Otology, Rhinology & LaryngologyTsai et al
Original Article
Comprehensive Emergency Airway Response Team (EART) Training and Education: Impact on Team Effectiveness, Personnel Confidence, and Protocol Knowledge
Annals of Otology, Rhinology & Laryngology 1–7 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003489415619178 aor.sagepub.com
Angela C. Tsai, MD1, Gintas P. Krisciunas, MPH, MA1, Chris Brook, MD1, Krystyne Basa, BA1, Mauricio Gonzalez, MD2, Janet Crimlisk, RN3, Julie Silva, RRT4, and Gregory A. Grillone, MD1
Abstract Objective: To evaluate the efficacy and utility of simulation of the Emergency Airway Response Team (EART) at a tertiary care hospital to improve team dynamics and confidence and knowledge in managing an emergency airway. Methods: This was a descriptive, quantitative performance improvement study. From September 1, 2013, to December 1, 2013, 177 members of the EART from anesthesia, otolaryngology, trauma surgery, emergency medicine, ICU nursing, and respiratory therapy participated in emergency airway simulations. Team dynamics and confidence levels and knowledge of EART were assessed using pre-and post-simulation questionnaires. Results: All participants regardless of their role, experience in the medical field, or any prior exposure to a difficult airway showed significant improvement in self-rated team participation and confidence and objective knowledge regarding EART after undergoing simulation. Conclusion: Our study highlights the efficacy and utility of simulation in assessing personnel team dynamics and confidence levels and knowledge of emergency airway scenarios. Practitioners in all fields and level of experience benefit in EART training and simulation. We hope that with this information, we will be able to conduct future studies on reduction of patient morbidity and mortality. Keywords difficult airway, patient safety, cricothyrotomy, simulation, teamwork
Background Inability to intubate and ventilate patients is associated with significant morbidity and mortality. A difficult airway increases this risk exponentially and can lead to complications such as pulmonary aspiration, esophageal intubation, hypoventilation, hypoxia, anoxic brain injury, and death.1 A difficult airway occurs when an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient’s lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy. In 2000, Showan and Sestito2 proposed that the components of a successful airway management system include personnel, training, an emergency response system, an oversight process, standardized equipment, and patient education. Although a traditional approach to improving patient outcomes has been to address individual knowledge and skills, it is now recognized that a significant number of
complications result from team rather than individual failures.3 Highly effective team performance and skill proficiency are crucial to successful outcomes in the management of the difficult airway. It is well documented that repeated simulation can improve communication among team members and 1
Department of Otolaryngology, Boston Medical Center, Boston, Massachusetts, USA 2 Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA 3 Department of Nursing, Boston Medical Center, Boston, Massachusetts, USA 4 Department of Respiratory Therapy, Boston Medical Center, Boston, Massachusetts, USA Corresponding Author: Angela C. Tsai, MD, Department of Otolaryngology, Boston Medical Center, FGH Building, 4th floor, Boston, MA 02118, USA. Email: [email protected]
Downloaded from aor.sagepub.com at CMU Libraries - library.cmich.edu on December 27, 2015
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Annals of Otology, Rhinology & Laryngology
Table 1. Questionnaire Content. Confidence Assessment
Knowledge Assessment
Physicians, nurses, and respiratory therapists work well together. There are clear lines of communication between MD, RN, and RT staff. It is easy to speak up if I perceive a problem with how the patient is managed. I have a good understanding of my roles and responsibilities in an EART situation. I feel that I have had adequate training to be an effective member of an interdisciplinary EART team. I feel confident that I will be able to recognize changes in my real patient’s condition. I feel confident in my Emergency Airway decision-making skills. I feel prepared to care for patients in a real EART scenario. I would feel safe being a patient treated by our EART team. Simulation training is important to practice clinical skills.
Who can activate the Emergency Airway Response Team (EART)? Anesthesia/emergency/surgical attending or resident What number do you call for the EART? Call 4-7777, state the campus, floor, room number, and unit extension number What is the EART team comprised of? Anesthesia/emergency/ENT/trauma attending and resident, respiratory therapy, resource nurse, SICU nurse True/false: An emergency airway cart is located in each ICU. False A patient is a difficult intubation. How does the staff convey this? Place the difficult intubation sticker on the end of the endotracheal tube A failed airway exists when there are 3 failed attempts at intubation even when the SaO2 is maintained. True What is the best example of closed loop communication? Inform the team leader when a task begins or ends such as “the endotracheal tube is secured.” In order to success a highly acute difficult airway situation, staff need to know their roles and responsibilities. What is not an appropriate role? The radiology attending is the MD team leader when an EART occurs in the radiology suite True/false: All members of a team management of a difficult airway are encouraged to speak up if something doesn’t feel right or seem right. True The elements of an effective emergency team include all the following except: Multitasking for all team members
improve competency in skills and procedures in multiple fields, including pediatrics, obstetrics and perinatal care, critical care, and cardiothoracic surgery.4-7 In 2009, Boston Medical Center implemented an Emergency Airway Response Team (EART) to manage highrisk airway cases across all hospital settings including the operating rooms, emergency department, inpatient floors, and outpatient facilities.8 However, an institution-wide multidisciplinary EART training and assessment program had not been developed and implemented. Given that current evidence supports education and training of all personnel involved in scenarios such as airway emergencies, an internal training grant was obtained to provide simulation training to members of the EART. The primary aims of this study were to evaluate (1) perception of personal confidence and team dynamics and (2) knowledge of the EART protocol. With this and subsequent training, it is hoped that interdisciplinary training in high-risk, low frequency events will ultimately reduce morbidity and mortality of difficult airway cases.
Methods This was a descriptive, quantitative performance improvement study. From September 1, 2013, to December 31, 2013, 177 members of the EART multidisciplinary team, including personnel from anesthesia, otolaryngology,
trauma surgery/critical care, emergency medicine, nursing, and respiratory therapy, participated in 24 EART simulations at the Solomont Simulation Center at Boston Medical Center (BMC). Each session included the following components in sequential order: orientation, pre-simulation questionnaire on EART knowledge, pre-simulation team dynamic/personal confidence questionnaire, education on the EART protocol, simulation session 1 followed by a debriefing, simulation session 2 followed by a debriefing, and finally the post-simulation EART knowledge and team dynamic/personal confidence questionnaires. This quality improvement project was subsequently reviewed and approved by the Institutional Review Board at BMC.
Questionnaire A comprehensive 3-part pre-simulation questionnaire assessed demographics (role in team, number of years of practice in their clinical specialty, location of practice at BMC, and prior experience with EART), EART-related personal confidence and team dynamics, and EART knowledge of processes and protocols. Questions assessing participants’ perception of team dynamics and confidence can be seen in Table 1. Responses to these questions were rated using the following scale: 1 = strongly disagree, 2 = somewhat disagree, 3 = neutral, 4 = somewhat agree, and
Downloaded from aor.sagepub.com at CMU Libraries - library.cmich.edu on December 27, 2015
3
Tsai et al 5 = strongly agree. Knowledge questions focused on EART protocol and processes and included items such as how to activate the EART, who is involved in the EART, location of airway carts, definition of a failed airway, proper communication of a difficult airway, and elements of effective communication (Table 1). There were a total of 10 knowledge-specific questions with single correct answer multiple-choice responses. The post-simulation questionnaire included the same confidence and knowledge questions as the pre-simulation questionnaire. Questionnaires were administered through Survey Monkey. All responses were collected anonymously and analyzed in aggregate.
Simulation
Figure 1. Participant demographics.
Sessions occurred at 7:30 am at the Solomont Simulation Center at BMC and lasted 2.5 hours each. The first 45 minutes included orientation and time to answer the pre-simulation questionnaire. Two simulation sessions then followed, each of which included a 15-minute simulation followed by a 30- to 45-minute debriefing session. The sessions concluded with answering the post-simulation questionnaire. There were 3 facilitators for each session, 1 to evaluate nursing, 1 to evaluate respiratory therapy, and the third to evaluate physicians. Each simulation group had 10 to 11 trainees. The setting of the simulation occurred in either the emergency department or interventional radiology. Scenarios began with an intubated patient who started to decompensate and who could not be ventilated or suctioned by a nurse and respiratory therapist. The scenarios progressed through a code blue and ended with the need to call for the Emergency Airway Response Team for advanced management and for a potential surgical airway. Without being told in advance, the teams repeated the first scenario so that they could correct any errors in managing either the patient and/or response to the difficult airway. Debriefing consisted of a lead facilitator and 2 secondary facilitators. Audio and video recordings of each simulation were available during the debriefing for review by the facilitators and participants.
Statistical Analysis For comparison of pre- and post-simulation questionnaire scores, data were analyzed using ANOVA testing. In all analyses, a value of P < .01 was used to indicate statistical significance.
Figure 2. Summary of team dynamics and confidence assessment scores according to individual questions.
residents, 63 of 177 (35.6%) were nurses, 25 of 117 (14.1%) were respiratory therapists, and 3 of 177 (1.7%) were listed as “other” (Figure 1). Eighty-nine of 177 (50.2%) had ≤5 years of experience in the medical field, 17 of 177 (15.2%) had 5 to 15 years, 51 of 177 (28.8%) had >15 years. Seventytwo of 177 (40.7%) participated in a prior EART, 90 of 177 (50.8%) did not, and 15 of 177 (8.5%) were unsure.
Team Dynamics and Confidence Assessment Results Demographics There were 177 participants from the departments of otolaryngology, anesthesiology, trauma surgery/critical care, emergency medicine, nursing, and respiratory therapy. Ten of 177 (5.6%) were attendings, 76 of 177 (42.9%) were
Mean scores for team dynamic and confidence assessment questions for all participants pre- and post-simulation are listed in Figure 2 and Table 2. The score indicates to what degree the participant agrees with the question (1 = strongly disagree, 5 = strongly agree). There was a significant increase in scores for all questions except for “I feel confident that I will be able to recognize changes in my real patient’s condition” and
Downloaded from aor.sagepub.com at CMU Libraries - library.cmich.edu on December 27, 2015
4
Annals of Otology, Rhinology & Laryngology
Table 2. Summary of Team Dynamics and Confidence Assessment Scores for All Participants. Average Score (1-5) Question 1. Physicians, nurses, and respiratory therapists work well together. 2. There are clear lines of communication between MD, RN, and RT staff. 3. It is easy to speak up if I perceive a problem with how the patient is managed. 4. I have a good understanding of my roles and responsibilities in an Emergency Airway Response Team (EART) situation. 5. I feel that I have had adequate training to be an effective member of an interdisciplinary EART team. 6. I feel confident that I will be able to recognize changes in my real patient’s condition. 7. I feel confident in my Emergency Airway decision-making skills. 8. I feel prepared to care for patients in a real EART scenario. 9. I would feel safe being a patient treated by our EART team. 10. Simulation training is important to practice clinical skills. Table 3. Percentage Correct in Knowledge Assessment Preand Post-Simulation. Percentage Correct Role
Pre-Simulation
Post-Simulation
Attendings 67.0 94.0 Residents 71.4 91.7 Nurses 72.7 92.4 Respiratory 75.2 89.6 therapists Other 66.7 86.7 Years of experience 0-5 years 70.3 92.0 5-15 years 70.7 90.8 >15 years 76.3 92.0 Prior Emergency Airway Response Team (EART) No 68.7 92.2 Yes 77.6 91.3 Unsure 66.0 90.7 Total 70.6 90.9
P Value
research-article2015
AORXXX10.1177/0003489415619178Annals of Otology, Rhinology & LaryngologyTsai et al
Original Article
Comprehensive Emergency Airway Response Team (EART) Training and Education: Impact on Team Effectiveness, Personnel Confidence, and Protocol Knowledge
Annals of Otology, Rhinology & Laryngology 1–7 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003489415619178 aor.sagepub.com
Angela C. Tsai, MD1, Gintas P. Krisciunas, MPH, MA1, Chris Brook, MD1, Krystyne Basa, BA1, Mauricio Gonzalez, MD2, Janet Crimlisk, RN3, Julie Silva, RRT4, and Gregory A. Grillone, MD1
Abstract Objective: To evaluate the efficacy and utility of simulation of the Emergency Airway Response Team (EART) at a tertiary care hospital to improve team dynamics and confidence and knowledge in managing an emergency airway. Methods: This was a descriptive, quantitative performance improvement study. From September 1, 2013, to December 1, 2013, 177 members of the EART from anesthesia, otolaryngology, trauma surgery, emergency medicine, ICU nursing, and respiratory therapy participated in emergency airway simulations. Team dynamics and confidence levels and knowledge of EART were assessed using pre-and post-simulation questionnaires. Results: All participants regardless of their role, experience in the medical field, or any prior exposure to a difficult airway showed significant improvement in self-rated team participation and confidence and objective knowledge regarding EART after undergoing simulation. Conclusion: Our study highlights the efficacy and utility of simulation in assessing personnel team dynamics and confidence levels and knowledge of emergency airway scenarios. Practitioners in all fields and level of experience benefit in EART training and simulation. We hope that with this information, we will be able to conduct future studies on reduction of patient morbidity and mortality. Keywords difficult airway, patient safety, cricothyrotomy, simulation, teamwork
Background Inability to intubate and ventilate patients is associated with significant morbidity and mortality. A difficult airway increases this risk exponentially and can lead to complications such as pulmonary aspiration, esophageal intubation, hypoventilation, hypoxia, anoxic brain injury, and death.1 A difficult airway occurs when an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient’s lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy. In 2000, Showan and Sestito2 proposed that the components of a successful airway management system include personnel, training, an emergency response system, an oversight process, standardized equipment, and patient education. Although a traditional approach to improving patient outcomes has been to address individual knowledge and skills, it is now recognized that a significant number of
complications result from team rather than individual failures.3 Highly effective team performance and skill proficiency are crucial to successful outcomes in the management of the difficult airway. It is well documented that repeated simulation can improve communication among team members and 1
Department of Otolaryngology, Boston Medical Center, Boston, Massachusetts, USA 2 Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA 3 Department of Nursing, Boston Medical Center, Boston, Massachusetts, USA 4 Department of Respiratory Therapy, Boston Medical Center, Boston, Massachusetts, USA Corresponding Author: Angela C. Tsai, MD, Department of Otolaryngology, Boston Medical Center, FGH Building, 4th floor, Boston, MA 02118, USA. Email: [email protected]
Downloaded from aor.sagepub.com at CMU Libraries - library.cmich.edu on December 27, 2015
2
Annals of Otology, Rhinology & Laryngology
Table 1. Questionnaire Content. Confidence Assessment
Knowledge Assessment
Physicians, nurses, and respiratory therapists work well together. There are clear lines of communication between MD, RN, and RT staff. It is easy to speak up if I perceive a problem with how the patient is managed. I have a good understanding of my roles and responsibilities in an EART situation. I feel that I have had adequate training to be an effective member of an interdisciplinary EART team. I feel confident that I will be able to recognize changes in my real patient’s condition. I feel confident in my Emergency Airway decision-making skills. I feel prepared to care for patients in a real EART scenario. I would feel safe being a patient treated by our EART team. Simulation training is important to practice clinical skills.
Who can activate the Emergency Airway Response Team (EART)? Anesthesia/emergency/surgical attending or resident What number do you call for the EART? Call 4-7777, state the campus, floor, room number, and unit extension number What is the EART team comprised of? Anesthesia/emergency/ENT/trauma attending and resident, respiratory therapy, resource nurse, SICU nurse True/false: An emergency airway cart is located in each ICU. False A patient is a difficult intubation. How does the staff convey this? Place the difficult intubation sticker on the end of the endotracheal tube A failed airway exists when there are 3 failed attempts at intubation even when the SaO2 is maintained. True What is the best example of closed loop communication? Inform the team leader when a task begins or ends such as “the endotracheal tube is secured.” In order to success a highly acute difficult airway situation, staff need to know their roles and responsibilities. What is not an appropriate role? The radiology attending is the MD team leader when an EART occurs in the radiology suite True/false: All members of a team management of a difficult airway are encouraged to speak up if something doesn’t feel right or seem right. True The elements of an effective emergency team include all the following except: Multitasking for all team members
improve competency in skills and procedures in multiple fields, including pediatrics, obstetrics and perinatal care, critical care, and cardiothoracic surgery.4-7 In 2009, Boston Medical Center implemented an Emergency Airway Response Team (EART) to manage highrisk airway cases across all hospital settings including the operating rooms, emergency department, inpatient floors, and outpatient facilities.8 However, an institution-wide multidisciplinary EART training and assessment program had not been developed and implemented. Given that current evidence supports education and training of all personnel involved in scenarios such as airway emergencies, an internal training grant was obtained to provide simulation training to members of the EART. The primary aims of this study were to evaluate (1) perception of personal confidence and team dynamics and (2) knowledge of the EART protocol. With this and subsequent training, it is hoped that interdisciplinary training in high-risk, low frequency events will ultimately reduce morbidity and mortality of difficult airway cases.
Methods This was a descriptive, quantitative performance improvement study. From September 1, 2013, to December 31, 2013, 177 members of the EART multidisciplinary team, including personnel from anesthesia, otolaryngology,
trauma surgery/critical care, emergency medicine, nursing, and respiratory therapy, participated in 24 EART simulations at the Solomont Simulation Center at Boston Medical Center (BMC). Each session included the following components in sequential order: orientation, pre-simulation questionnaire on EART knowledge, pre-simulation team dynamic/personal confidence questionnaire, education on the EART protocol, simulation session 1 followed by a debriefing, simulation session 2 followed by a debriefing, and finally the post-simulation EART knowledge and team dynamic/personal confidence questionnaires. This quality improvement project was subsequently reviewed and approved by the Institutional Review Board at BMC.
Questionnaire A comprehensive 3-part pre-simulation questionnaire assessed demographics (role in team, number of years of practice in their clinical specialty, location of practice at BMC, and prior experience with EART), EART-related personal confidence and team dynamics, and EART knowledge of processes and protocols. Questions assessing participants’ perception of team dynamics and confidence can be seen in Table 1. Responses to these questions were rated using the following scale: 1 = strongly disagree, 2 = somewhat disagree, 3 = neutral, 4 = somewhat agree, and
Downloaded from aor.sagepub.com at CMU Libraries - library.cmich.edu on December 27, 2015
3
Tsai et al 5 = strongly agree. Knowledge questions focused on EART protocol and processes and included items such as how to activate the EART, who is involved in the EART, location of airway carts, definition of a failed airway, proper communication of a difficult airway, and elements of effective communication (Table 1). There were a total of 10 knowledge-specific questions with single correct answer multiple-choice responses. The post-simulation questionnaire included the same confidence and knowledge questions as the pre-simulation questionnaire. Questionnaires were administered through Survey Monkey. All responses were collected anonymously and analyzed in aggregate.
Simulation
Figure 1. Participant demographics.
Sessions occurred at 7:30 am at the Solomont Simulation Center at BMC and lasted 2.5 hours each. The first 45 minutes included orientation and time to answer the pre-simulation questionnaire. Two simulation sessions then followed, each of which included a 15-minute simulation followed by a 30- to 45-minute debriefing session. The sessions concluded with answering the post-simulation questionnaire. There were 3 facilitators for each session, 1 to evaluate nursing, 1 to evaluate respiratory therapy, and the third to evaluate physicians. Each simulation group had 10 to 11 trainees. The setting of the simulation occurred in either the emergency department or interventional radiology. Scenarios began with an intubated patient who started to decompensate and who could not be ventilated or suctioned by a nurse and respiratory therapist. The scenarios progressed through a code blue and ended with the need to call for the Emergency Airway Response Team for advanced management and for a potential surgical airway. Without being told in advance, the teams repeated the first scenario so that they could correct any errors in managing either the patient and/or response to the difficult airway. Debriefing consisted of a lead facilitator and 2 secondary facilitators. Audio and video recordings of each simulation were available during the debriefing for review by the facilitators and participants.
Statistical Analysis For comparison of pre- and post-simulation questionnaire scores, data were analyzed using ANOVA testing. In all analyses, a value of P < .01 was used to indicate statistical significance.
Figure 2. Summary of team dynamics and confidence assessment scores according to individual questions.
residents, 63 of 177 (35.6%) were nurses, 25 of 117 (14.1%) were respiratory therapists, and 3 of 177 (1.7%) were listed as “other” (Figure 1). Eighty-nine of 177 (50.2%) had ≤5 years of experience in the medical field, 17 of 177 (15.2%) had 5 to 15 years, 51 of 177 (28.8%) had >15 years. Seventytwo of 177 (40.7%) participated in a prior EART, 90 of 177 (50.8%) did not, and 15 of 177 (8.5%) were unsure.
Team Dynamics and Confidence Assessment Results Demographics There were 177 participants from the departments of otolaryngology, anesthesiology, trauma surgery/critical care, emergency medicine, nursing, and respiratory therapy. Ten of 177 (5.6%) were attendings, 76 of 177 (42.9%) were
Mean scores for team dynamic and confidence assessment questions for all participants pre- and post-simulation are listed in Figure 2 and Table 2. The score indicates to what degree the participant agrees with the question (1 = strongly disagree, 5 = strongly agree). There was a significant increase in scores for all questions except for “I feel confident that I will be able to recognize changes in my real patient’s condition” and
Downloaded from aor.sagepub.com at CMU Libraries - library.cmich.edu on December 27, 2015
4
Annals of Otology, Rhinology & Laryngology
Table 2. Summary of Team Dynamics and Confidence Assessment Scores for All Participants. Average Score (1-5) Question 1. Physicians, nurses, and respiratory therapists work well together. 2. There are clear lines of communication between MD, RN, and RT staff. 3. It is easy to speak up if I perceive a problem with how the patient is managed. 4. I have a good understanding of my roles and responsibilities in an Emergency Airway Response Team (EART) situation. 5. I feel that I have had adequate training to be an effective member of an interdisciplinary EART team. 6. I feel confident that I will be able to recognize changes in my real patient’s condition. 7. I feel confident in my Emergency Airway decision-making skills. 8. I feel prepared to care for patients in a real EART scenario. 9. I would feel safe being a patient treated by our EART team. 10. Simulation training is important to practice clinical skills. Table 3. Percentage Correct in Knowledge Assessment Preand Post-Simulation. Percentage Correct Role
Pre-Simulation
Post-Simulation
Attendings 67.0 94.0 Residents 71.4 91.7 Nurses 72.7 92.4 Respiratory 75.2 89.6 therapists Other 66.7 86.7 Years of experience 0-5 years 70.3 92.0 5-15 years 70.7 90.8 >15 years 76.3 92.0 Prior Emergency Airway Response Team (EART) No 68.7 92.2 Yes 77.6 91.3 Unsure 66.0 90.7 Total 70.6 90.9
P Value
