Xiao video by Udc4XK1S

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									Simulation, Live teams and Videotape:
   All for the sake of patient safety

                    Yan Xiao, PhD
                Professor of Anesthesiology
         University of Maryland School of Medicine
                    Shock Trauma Center
                 Baltimore, Maryland, USA

 Director, Research in Patient Safety, Program in Trauma
 Associate Director for Research, Center for Advancement of
 Patient Safety at University of Maryland (CAPSUM)
 University of Maryland Medical Center
       Engineering and Anesthesiology


“Consciousness is routinely interrupted by general
anesthetics.

The loss of consciousness under anesthesia and the later
recovery of it can, in principle,
surely be elucidated as thoroughly
as any other drug-induced changes”

Fink, Scientific American
            Why Videotaping?
•   Illustration and education
•   Detailed study
•   Performance evaluation
•   etc
             Videotaping at
         University of Maryland
• Emergency airway management
• Glidescope versus laryngoscope
• Team performance modeling and evaluation
• Errors in subclavian central venous line
  catheterization
• Monitoring behaviors and alarms responses
• Debriefing and teaching of trauma resuscitation
• Video for OR management
All trauma bays, operating rooms (+more) are
wired with cameras (>100 cameras)
It’s real!                           Cropped view field
Transient/ critical visual cues      Face blurring
Non-verbal coordination




 Priority I admission, circa 1990.
Anatomy of a prolonged, uncorrected, esophageal intubation

                               Anesth 1996; 84:1495-503
Parallel tasks         Poor ergonomics (alarms, CO2 analyze
Anticipatory support   Poor skilled performance under stress




         Priority I admission, circa 1990.
  Esophageal Intubation
• 37% (762/2046) adverse outcomes caused by
  incorrect tube placement, hypoxia & difficult
  airways (Anesth 1990;72:828-33)
Major Pitfalls Emergency Airway
          Management
“THE THREE C’s”
• CO2 ANALYSIS DELAYED after
  intubation in emergencies
• CLINICAL EXAM DELEGATED to
  someone other than the intubator
• COMMUNICATION FAILURES of
  clinical findings on chest exam after
  intubation
       Analytical Approaches
• Task template (checklist) based for
  procedural omissions and timings
• Case studies of critical incidents with
  principles of team communication,
  coordination, and ergonomics
   Video analysis helped finding
   solutions




Original Circuit( left ) no CO2 analysis
possible with bag-valve-mask. Modified
  Circuit ( right ) allows CO2 analysis
               immediately
   Outcomes from Video –Based
   Assessment of Emergency &
        Elective intubation
• 1992 – Prolonged uncorrected esophageal
  intubation ( Anesth 1996;84:1495-503)
• 1993 -Implement Task/Communication Algorithm
  and Insert connector for CO2 analysis
• 10 year follow-up of QA monthly reports
  identifies that no recurrence of undetected
  esophageal intubation among > 14,000 intubations
  performed
• In same patient population 2.5% incidence of
  esophageal intubation when field intubated
Glidescope in Teaching Airway
      Management Skills
        Analytical Approach
• Glidescope vs direct laryngoscopy for
  emergency intubation, Dale Yeatts MD;
  Richard Dutton MD; Thomas Grissom MD;
  Peter Hu. Contact: dyeatts@umm.edu
• Hypoxia during DL as a function of pre-
  oxygenation, re-oxygenation, & techniques
  (e.g., DL vs glidescope)
• 500 cases recorded so far
Dynamic Delegation and Team
        Leadership
       Analytical Approaches
• Communication patterns as an indication of
  team structure
• Variations of team structure as a function of
  team experience and task criticality
                      L
                    Attend
                     -ing             Experience Factor on Team
         19%                           Communication Patterns
                                   25%      12%
                              7%
               8%


   S                 3%
                                    J
                                   Resi-
Fellow                             dent
                15%                        5%                                L
                                                                           Attend
                                                 C
                                                                            -ing
                                                Other
                             6%
                                                                 9%
                                                                      6%                  9%       2%
                                                                                    4%



                                                           S                               J
                                                                           8%             Resi-
                                                        Fellow                            dent
                                                                           35%                    10%
                                                                                                         C
                                                                                                        Other
                                                                                    18%
             Opinion leaders
             Publication of consensus
             National performance measures
             Managed care quality indicators
             “Business-like responses” (letters,
             case manager scripts)
             Financial incentives




The case of Beta Blocker, Lee NEJM Sept 20, 2007
       Systems Approach to
       Guideline Compliance
• Compliance is a property of the healthcare delivery
  system, not that of individual choices
• The delivery system consists of
   –   The socio-economic environment (eg incentives)
   –   The organization (eg culture and norms)
   –   The physical environment (eg workplace design)
   –   The monitoring/feedback systems (e.g., audit)
   –   The individual
• Human Factors
   – Knowledge, skills, attitude
   – Barriers of all kinds (e.g., memory failures)
Central Venous Catheterization (CVC) as a Task
       Model for Patient Safety Research
• Clinically significant: More than 15% of Central
  Venous Catheters develop complicationsa (unintended
     arterial puncture, hematoma, hemothorax and pneumothorax, thrombotic
     and infectious)
• 80,000 blood stream infection (BSI) cases occur
  annually in ICUsa
• National average 5.3 BSI/1000 catheter days b
• Attributable mortality rates of 12-25%c
• Prolonged hospitalization (7.4 days)
• Marginal attributable cost $34-56,000 per BSI, up to
  $2.4 billion annuallyc
aNEngl J Med 2003; 348: 1123-33.     bAm   J Infect Control 2003; 31:481-98.
cMMWR 2002;51(No. RR-10):1-29.
      Results of          2 nd   Operators
• Overall 140 CVC insertions analyzed
• 58 CVC insertions included a single secondary operator
  assisting
   – 90% MBP compliance of primary operators
   – 66% MBP compliance of secondary operators
• In elective CVC insertions
   – 88% MBP compliance in primary operators (n=113)
   – 72% MBP compliance in secondary operators (n=47)
               Analytical Approach
• Formalized review of
  practices
  – Computer aided video-
    review
  – Structured checklist for
    procedure
  – Teaching points
    indicated in free text
• Example clips
  extracted
  – Positive and negative
    examples of
    performance
Examples of Breaks in Sterile Technique


• Excessive movement of drapes
• Repositioning nonsterile drapes over sterile fields
• Cutting holes in full-body drapes, revealing nonsterile
  fields
• Not removing electrocardiogram leads from the sterile
  field
• Performing skin preparation after gowning but not waiting
  for adequate drying time
• Including cervical collars in the sterile field after draping
Example video
 What is wrong with this technique?
Engage the users
  Evaluation of Video Based Web
             Training
• End-point: compliance to maximum barrier
  protection
• Intervention: video based web training
  versus paper printout
• Subjects: residents rotating through trauma
  services
• Assignment:
   – Video: residents starting Months 1 and 4
   – Paper: residents starting Months 2 and 3
• Data collection: video recording of all lines
  placed during Monday-Saturday, 12 noon to
  12 midnight.
Compliance odds ratio: 6.1 [1.96-22.03]
                  Results
• Stepwise logistic regressions (variables:
  years of training, specialty, number of
  CVCs placed in the study, site of insertion,
  and training groups): power=0.84
• Only training group assignment was the
  significant predictor.
• Compliance odds ratio: 6.1 [1.96-22.03]
              Discussions
• Course was short (<1h), self-paced, viewed
  anywhere
• Real-life video clips
• Course linked with published references
Secondary Operator
Alarms



How intrusive are they?
How informative are they?
“Why Are They Not Responding to Our Alarms?”
04:00.00 - 04:14.00   05:50:00
                      Ventilator   09:05.00 - 09:12.00
Pre-oxygenation       alarms       Preparing for induction




                      12:30:00
12:27.00 - 12:41.00   Ventilator   14:10.00 - 14:35.00
After intubation      alarms       Connecting to ventilator
         Analytic Approach
• Frequency of alarms
• Nature of alarms
• Operator responses
                                            Results: Silencing Frequencies
Percentage (mean/SEM) of silenced alarms


                                           100%               95%
                                                  90%                                 All (n=47)
                                           90%          84%               85%
                                                                                      Elective (n=19)
                                           80%
                                                                                      Emergency (n=28)
                                           70%                      66%

                                           60%                                  55%
                                           50%
                                           40%
                                                                                            29%
                                           30%
                                                                                      18%
                                           20%                                                     14%
                                           10%
                                            0%
                                                   Ventilator         BP/HR           ETCO2/SPO2
                                                     Results: Speed of silencing
                                               250
Duration (mean/SEM) of silenced alarms (sec)




                                                      All (n=47)
                                                      Elective (n=19)
                                               200    Emergency (n=28)



                                                                                                     147
                                               150



                                               100


                                                                                           56
                                                                                      45
                                                50
                                                                         35                     33
                                                                               23
                                                                    12
                                                       7       5
                                                 0
                                                           Ventilator         BP/HR        ETCO2/SPO2
      Alarm Strategies
• “Manufacturers make their alarms
  extremely intrusive in an attempt to ensure
  that their equipment can never be faulted
  because it failed to notify the user of an
  event.” -- Westenskow, 1996
• “the ease of disabling ventilator alarms
  either deliberately or inadvertently is
  overall the most important contributory
  factor in injuries” -- Cooper & Couvillon,
  1983
(pictures of eye tracker aparatus)
        Analytical Approach
• Posture analysis for ergonomics of device
  layout
• Eye-gaze patterns for information sampling
  activities
Video analysis showed poor
ergonomics
                                                                  140

                                                            L




                            Visual Deviation from Patient-focus
                                                                  120            Induction

                                                                  100            Intubation
                                                                                 Connection
                                                                  80

                                                                  60


                                                                  40


                                                                  20

                                                       J           0
                                                                        0
                                                                            J   20     40     60     80     100
                                                                                       Dispersion of Attention      L
                                                                                                                  120   140




                                                                  140

                                                            L




                            Visual Deviation from Patient-focus
                                                                  120            Induction

                                                                  100            Intubation
                                                                                 Connection
                                                                  80

                                                                  60


                                                                  40


                                                                  20

                                                       J           0
                                                                        0
                                                                            J   20     40     60     80     100
                                                                                       Dispersion of Attention      L
                                                                                                                  120   140




                        Visual deviation from patient (Y-axis) and
                        dispersion of attention (X-axis) for the observed
                        layout (A, top) and the two proposed improved
                        layout schemes (B, bottom). The proposed
                        improved layout graph shows a shift in downward
   HFES 20004, 1755-8   and to the left.
                               Routine Monitoring
             Definition: Periodic checks on patient and scanning of
             instruments during steady-state periods

             • Focus not on patient or monitoring-equipment
             • Occasional, cyclical, single checks to “stay current”
                       41:22     41:30   41:38   41:46   41:54   42:02   42:10   42:18


On Patient
Room, people
Lines
Flow Meters
Criticare Monitor
Mennen Monitor
Heart Rate
Heart Trace
Ventilator
Supplies
                         Problem Solving

             40:09    40:20    40:31    40:42    40:53    41:04

Patient
BP
Vitals
SpO2
CO2
Drugs
Bag area
Ventilator
Heart Rate
Alarm



       Differential diagnosis of Pneumothorax vs. hypovolemia
Patterns of Visual Sampling of Patient
Monitors During Airway Management

                        10

                            9

                            8

                            7
  Frequency of Monitoring




                            6
        (events/min)




                            5

                            4

                            3

                            2

                            1

                            0
                                Prep   Induction         Pre      Laryngoscopy/    1 minute post   Remaining time
                                                   laryngoscopy   Tube insertion   laryngoscopy
                                                     Stage of Monitoring
         Analytical Approach
• N: 8 real and 8 simulated
• % of time looking at the patient
  – Real: mean of 34 sec (58%±4.9%)
  – Simulated: a mean of 27 sec (47%±3%)
    (p<0.05)
• % of time looking at monitors
  – 6.1+/-0.9 sec versus 7.± 2.1 sec, p<0.05
   Case 1
44:00   Patient Arrival




51:21   Checking the pulse
52:25   Femoral line
53:02   Three procedures
54:44   Hanging Blood
55:12   Chest tube placement
Admission: 03:44 AM
03:51:21 Checking the pulse
03:52:25 Femoral line
03:53:02 Three procedures
03:54:44 Hanging blood
03:55:12 Chest tube placement
       OR Management (STC=Subject to Change)

• 17 (+8, 6-34) daily changes
   –   Canceling
   –   Adding
   –   Holding
   –   Changing orders
   –   Changing rooms)
• Highest changes
   – on Monday
   – Before 9AM
• Emergency cases (N=41) did not correlate
  with # of changes.
      Coordination & IT Support
• Collaborative work is the joint performance of
  people and surrounding artifacts
The operating room whiteboard in a trauma operating room suite (Video 16X speed)
                 Summary
• Video provides invaluable data on
  individual and team performance
  – Critical incident and performance analysis
  – Training and education
• Video is a powerful tool with double edges

								
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