Ross Bogart, SRNA Christine Fitzpatrick, SRNA Christopher Kaufman, SRNA

1. Student Registered Nurse Anesthetist’s Perceptions on the Use of High-Fidelity Manikin Simulators forAcquiring Intubation Skills Ross Bogart, SRNA Christine Fitzpatrick, SRNA Christopher Kaufman, SRNA

2. Presentation Objectives • Provide an overview of the thesis and why we chose to conduct this study. • Discuss findings regarding nurse anesthetists perceptions of manikin simulators and their limitations for acquiring intubation skills. • Discuss the options of high-fidelity simulation available for airway training. • Discuss the future of high-fidelity simulation.

3. Overview • Simulation-based training is a widely accepted educational tool commonly used by medical and nursing schools that allows students to experience scenarios in real time with an accurate interactive response. • Learn routine and advanced skills without harm to live patients.

4. Overview • Anesthesia providers use simulation-based or high-fidelity mannequins to acquire the advanced skill of intubation. • Literature is presented regarding the use of simulator training in medical and nursing fields with an emphasis on intubation training.

5. Literary Review • Reviewed literature provides evidence that high-fidelity simulation is an effective method of teaching advanced intubation skills necessary for the practice of anesthesia. • In addition, reviewed literature provides evidence that students − including nurse anesthesia students − appreciate simulation-based learning experiences.

6. Literary Review • This study will add to nursing's body of knowledge. Specifically, the study will identify perceptions of student registered nurse anesthetists in the use of high-fidelity simulation for acquiring intubation skills at one setting. • Findings provide educators of registered nurses in advanced practice roles insight to enhance simulation-based training experiences related to anesthesia practice.

7. Student Registered Nurse Anesthetist’s Perceptions on the Use of High-Fidelity Manikin Simulators forAcquiring Intubation Skills

8. Purpose • The purpose of this study was to identify perceptions of student nurse anesthetists regarding the use of high-fidelity patient simulation to acquire intubation skills.

9. Research Design • Mixed-design • Descriptive study • Both quantitative and qualitative data were collected • Survey technique

10. Setting • Conducted in a school of nursing at a private, Catholic university located in a northwestern Pennsylvanian city.

11. Sample • Enrolled student registered nurse anesthetists (SRNAs) in the educational setting at the time of data collection (May-July 2010). • A total of 20 surveys were distributed and 20 completed surveys were returned, yielding a 100% response rate.

12. Protection of Subjects • Approved by university’s Institutional Review Board. • Participation strictly voluntarily. • Data collected using survey technique. Returning completed survey implied consent. Participant confidentiality was ensured by: 1. No names or identifying data. 2. Findings reported in aggregate. • Data to be kept in a locked file for 3 years before being destroyed. • No risks to SRNA participating in study. • A specific benefit to participating was the knowledge that they were adding to anesthesia body of knowledge. Specifically, findings can enhance the experience of acquiring intubation skills using high-fidelity patient simulators. In addition, findings can enhance the decision-making process for student registered nurse anesthetists that can be transferred to actual clinical situations.

13. Instrument • The 15-item survey instrument used for data collection was developed specifically for this study and were based on factors identified in the review of literature. • 5 demographic data items — age, gender, whether or not they believe they acquired the necessary skills to begin attempting intubations in the clinical arena. • 8 closed- and 2 open-ended study items were used to answer the question under investigation. • Closed-ended study items were constructed using a 5-point Likert-type scaling system. Participants answered each question using verbal scaling cues ranging from “strongly disagree” to “strongly agree.” • Content validity of survey items was established by three university faculty with expertise in survey construction.

14. Procedures • Gained university’s IRB approval. • Collected data. • Analyzed data. • Conclusions.

15. Data Analysis • Demographic data and closed-ended study items were analyzed using descriptive statistics and findings are reported in the aggregate. • Open-ended study items were analyzed using thematic analysis and findings are reported in the narrative.

16. Results of the Study DemographicsData: • 55% Females & 45% Males • 90% were 25-40 years old • 45% worked as RNs less than 5 years • 65% were enrolled in an SRNA program 12 to 18months and 30% more than 24 months.

17. Results of the Study StudyData: • 75% strongly agree that intubation requires critical thinking. • 85% strongly agree that they were taught how to intubate using high-fidelity simulation. • 95% strongly agree and 5% agree they have successfully intubated patients in OR. • 70% and 25% strongly agree and somewhat agree, respectively, they are confident in their intubating skills.

18. Results of the Study StudyData (continued): • 85% strongly agree that clinical faculty instill confidence specific to their ability to intubation. • 25% agree that they experienced difficulty with mastering the skill and 65% disagree and 10% strongly disagree. • 100% strongly agree that they had at least one unsuccessful intubation in the OR. • 95% strongly agree that they successfully intubated a patient considered to be “difficult to intubate”.

19. Results of the Study • During analysis of responses the SRNA’s indicated that they like mannequin simulatorsbecause they: (1) allowed for practice of the intubation sequence, (2) provided the basic techniques of airway management, and (3) allowed for practice without the risk of injuring a real patient. • Also during analysis of responses the SRNA’s indicated that they found they did not like the mannequin simulators because the airways were not realistic.

20. Conclusions & Recommendations • A survey technique was used to answer the question under investigation. A survey instrument developed specifically for this study was distributed to the SRNAs. The sample size was small—a total of 20 SRNAs returned completed surveys—but important information was identified.

21. Conclusions & Recommendations • Replication of this study, using a larger sample size, is recommended. The small sample size of this study limits the ability to generalize findings. Sampling from more than one geographic region could also enhance, enrich, and validate current findings. • Conducting interviews—in addition to replicating the survey approach used for this study—is recommended, as interviews could elicit more focused data for analysis. Regardless of the method, it is important to continue investigating the perceptions of SRNAs on the use of high-fidelity patient simulation mannequin in acquiring intubation skills.

22. Anesthesia Providers are the Airway Experts! • Patient’s rely on us to protect their airway and provide adequate ventilation and oxygenation for them while under anesthesia. • Surgeon’s rely on us to manage the patient’s airway, vital signs, and anesthetic needs while they perform surgery.

23. Anesthetist have to start somewhere!!!

24. Every Airway is Different

25. Predictive Tests • < 10% of patients with features ‘predicting’ difficult laryngoscopy prove to be difficult to intubate 50% of difficult cases are not predicted by the tests • Thyromentaldistance (Patil test) <6cm predicts 75% of difficult laryngoscopies. • Sternomentaldistance (Savva Test)<12.5cm associated with difficulty positive predictive value of 82%. • Wilson Score (combines 5 factors: weight, upper cervical spine mobility, jaw movement, receding mandible and buckteeth) • Each are scored 0-2 • Total score > 2 predicts 75% of difficult intubations

26. Predictive Tests • Mallampati Views: If used alone, can correctly predicts 50% of difficult laryngoscopies… but it also has false positive rates of up to 90%.

27. Difficult Airway Assessment Mallampati Class IV • Receding Mandible • Short ramus • Protruding Incisors Mallampati Class III • Cervical Spine Immobility (<90%) • Obesity (excess tissue, large tongue, etc.) • Thyromental distance <6cm Interincisor distance of <3cm • TMJ • Airway tumors • Small mouth • Decreased jaw mobility • Poor dentition • Beard (visualization issue)

28. Difficult Airways

29. Difficult Airways

30. Difficult Airways

31. Looking at the Numbers • Intubation is difficult in 1:50 cases • Intubation is impossible in 1:2000 cases • Intubation is impossible in emergencies 1:200 cases • Face mask ventilation is impossible in 1:1500

32. What Manikins can do: Simulate decreased neck mobility. Simulate increased tongue edema and obstructed airway. Demonstrate results of endotracheal and right main stem intubation. Allow safe practice of retrograde intubation & percutaneous transtracheal jet ventilation

33. What mannequins can do: Transparent walls of the pharynx and trachea: • Permit supervision of the learner's performance. • Enables the learner to follow the tube down the throat.

34. What mannequins can do: Practice the management of obstructed airway, airway blockage and needle and surgical cricothyrotomy.

35. Mannequins Limitations: • Congenital airway difficulties • Pierre Robin Syndrome • Klippel-feil Syndrome • Downs Syndrome • Crouzon Syndrome • Apert Syndrome • Hemicraniofacial microsomia • Romberg disease • Treacher Collins syndrome • Grieg Syndrome • Medical conditions associated with difficult intubation: • Rheumatoid arthritis • Ankylosing spondylitis • Acromegaly • Pregnancy • Obesity • Cretinism • Burns & Infections • Trauma • Tumors

36. Head and Upper Airway AnatomicalAdult & ChildIntubationTrainer • Simulates anatomical features relevant to intubation. • Simulates anatomical changes caused by movements of the head, cervical spine, and jaw. • Teaches and allows practice of intubation, nasotracheal intubation, suctioning, and the use of laryngoscopes, airways, and other resuscitation devices. • Cutaway section of the left side of the head shows the transparent walls of the pharynx and trachea. • Suitable for ACLS training.

37. Head and Upper Airway • Deluxe Difficult Airway Head

38. Head and Torso • AdvancedIntubationTrainer • Tongue swelling • Laryngospasms • More tracheal space for improved maneuvering • Apply cricoid pressure, change the position of the trachea, and close the esophagus in order to practice the Sellick maneuver

39. Head and Torso CriticalCareAirwayTrainer • Difficult intubation head + CPR torso challenges for initiating respiratory care to critical patient. • Tongue swelling • Laryngospasms • Instructional scenario that requires student to perform a cricothyrotomy. • Additionally, two external and one internal bleeding wounds demand attention with suctioning and bleeding control.

40. Head and Torso AirwayManagementTrainer‘s • Simulates real-world complications when practicing a variety of intubation, ventilation, and suction techniques. • Realistic features allow Sellick Maneuver and laryngospasm • Practice clearing an obstructed airway and suctioning • Visual inspection of lung expansion and auscultation • Simulates stomach inflation and vomiting situation • Airway demonstration

41. Suggested Airway SimulationsThat can be done on a Manikin • Use the Difficult Airway Algorithm to practice difficult airway scenarios. • Practice alternative approaches: • Repositioning head (ramp) • Changing laryngoscope blades • Use LMA as intubating stylet • Retrograde Guidewire • Nasal intubations • Combitube • Light wand • Glidescope • Semi-rigid stylets (Bouge)

42. The Future of Simulation in Anesthesia

43. Anesthesia Training and Education • Information Age changes every facet of our lives, but the education of healthcare professionals is hindered in the 100-year-old apprenticeship model exemplified by the phrase “see one, do one, teach one.” • Anesthesia care has become increasingly complex and medical error has become a substantial problem. • Current academic health centers provide opportunity to rethink the way medical education is delivered across a continuum of the profession.

44. Anesthesia Training and Education • Simulation is an accepted part of training, assessment, and research in aviation, nuclear power, and the military leading to a higher standard of training in the fields. • Major advances in technology and tools in healthcare simulation have been made over recent decades. Cost of equipment and training educators to use the equipment slowed progress of use in educating anesthesia providers until recently. • Results of this study and previous studies shows the benefits of high-fidelity simulation training in the field of anesthesia.

45. Anesthesia Training and Education • Key aspect of the anesthesia practice is the ability to perform practical procedures efficiently and safely. • Decreased working hours during training, increasing focus on patient safety, and greater accountability have resulted in a paradigm shift in anesthesia education. • Benefits of training on high-fidelity patient simulators in realistic clinical scenarios gives educators opportunity to place students in different clinical situations and help them critically think through how to react. • Allows educators and students to analyze and assess competency.

46. Anesthesia Training and Education • High-fidelity patient simulators improve diagnostic and therapeutic decision-making skills. • Increases the self-confidence and competency of the anesthesia provider. • Simulators allow the anesthesia provider to see their deficits and learn from mistakes prior to facing the same scenario with a patient in the OR.

47. Anesthesia Training and Education • Proficiency on a simulator does not ensure proficiency in clinical settings. High-fidelity simulation, or how accurately the simulator replicates reality, is imperfect. • Very difficult to "re-create" human response given all the variables that can occur in a live setting. • Each patient has a different set of variables anesthesia provider must deal with. • Simulation gives anesthesia provider the chance to hone critical thinking skills in situations they may not see experience in a clinical setting, like MH.

48. Eye to the Future • Increasing use of simulation and availability of learning modules will improve anesthesia education. • Provide real benefits to patient care: • enhanced, safer, and cheaper. • Within 5 years, use of high-fidelity patient simulators, virtual reality, and Web-based electronic learning will grow to be a large part of education, certification and recertification of anesthesia providers.

49. Continuing Research is Needed • Continued research in the field continues to measure validity of training by high-fidelity patient simulators and how it correlates to the improvement of patient safety and outcomes. • Continued improvements to training modules and accuracy of patient simulators and simulation will become the training tool of the future.

50. References: Calder I et al. (2003). Mouth opening. A new angle. Anesthesiology, 99, 799-801 McQuillan, Patrick M. (2008). Airway Assessment and Management. Oxford American Handbook of Anesthesiology, 961-966 Cook TM (2003). A new practical classification of laryngeal view. Anesthesia, 55, 274-279 Schaeffer, J.J. (2004). Simulators and difficult airway management skills. Pediatric Anesthesia, 14, 28–37.