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Quality Control In Critical Care Training

Quality Control In Critical Care Training. By Zyllan Spilsbury (F2). Contents. Background Search criteria The paper Summary Validity Methodology Results Discussion. The Problem:. Intubation and acute airway management training for trainees. Learning curve vs. Kantian Ideal

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Quality Control In Critical Care Training

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  1. Quality Control In Critical Care Training By ZyllanSpilsbury (F2)

  2. Contents • Background • Search criteria • The paper • Summary • Validity • Methodology • Results • Discussion

  3. The Problem: • Intubation and acute airway management training for trainees. • Learning curve vs. Kantian Ideal • How do you find balance?

  4. What to do with airways? • Preparation • Pre-oxygenation • Premedication • Paralysis • Placement • Post management

  5. The Search:

  6. The Search

  7. The Search

  8. Paper: • The Usefulness of Design of Experimentation in Defining the Effect Difficult Airway Factors and Training Have on Simulator Oral-Tracheal Intubation Success Rates in Novice Intubators • Frank Thomas, Judi Carpenter, Carol Rhoades, Renee Holleran, Gregory Snow • Academic Emergency Medicine Journal • 2010; doi: 10.1111/j.1553-2712.2010.00706.x

  9. The study: • Full Factorial design of experimentation • Six factors (Straight vs curved blade, trismus, tongue oedema, laryngeal spasm, pharyngeal obstruction and cervical immobilization) • 64 airway scenarios were randomly assigned to 12 nurses (single blinded) • First pass intubation rates and tracheal intubation time before and after didactic training • Statistics: • Binary variable with intubation success measured as a linear model. • Two way interactions between the six factors

  10. Validity • Population • 12 Critical Care Transport Nurses (novice intubator) • Recruitment bias • Small study • Intervention • 4 hour didactic intubation training • 5 attempts at normal (grade 1) intubation • Comparison • Before and after training; • Null- Intubation success would not change between different difficult airway scenarios in the pre and post training cohorts • Outcome • First pass tracheal/oesophageal intubation rates • Tracheal Intubation time (laryngoscope entry to 3 successful breaths) • Study set out to detect a beneficial effect • No conflict of interests noted

  11. Methodology • Use of a model “Laerdal difficult airway simulator” • 64 different airway scenarios • Randomized Single blind study. Only randomized the first time. Bias. • How were they different? • Unknown how many scenarios each person underwent? • Training process- • 4hour program including airway adjuncts, RSI, observation of instructional video and 5 successful attempts at intubating the model • 3 month process from start to finish- • Other confounders?

  12. Results • Normal probability plots created to test the null hypothesis based on predictions • Straight blade, tongue oedema and laryngeal spasm all reduced first pass intubation. (p<0.01) • No difference in trismus, pharyngeal obstruction or cervical immobilization.

  13. Results- Reliability • All p values and CIs stated • Standard deviations for time to intubate quoted but large. • No statistical analysis of previous experience as confounder. • All figures are expressed as proportions (%) • How big were the sample sizes? • Wrong statistical test used for first attempt intubation • Chi squared instead of normal distribution analysis

  14. Relevance • Strange to assess “straight blade” as a “difficult airway” • Intubation time is an odd thing to measure as it will not necessarily correspond to safety • Assuming the results are robust: • Significant increase in first time intubation rates and times following training on a model. • Training on a model did not adversely affect intubation rate. • Specific study population-> results may differ in Drs or Anaesthetic trainees. No Control. • How good can models be compared to the real thing?

  15. Conclusions • Impossible to form perfect study as models are no substitute for humans • Small study group • Poorly randomized • Poor presentation of results (proportions) • Unusual outcomes • Odd statistical testing • Improvement in first pass intubation rate by training • Good idea but poor delivery

  16. Many Thanks! • Special Mention to Victoria Treadway. • References: 1) The Usefulness of Design of Experimentation in Defining the Effect Difficult Airway Factors and Training Have on Simulator Oral-Tracheal Intubation Success Rates in Novice Intubators. Frank Thomas, Judi Carpenter, Carol Rhoades, Renee Holleran, Gregory Snow. Academic Emergency Medicine Journal. 2010; doi: 10.1111/j.1553-2712.2010.00706.x 2) Difficult airway society guidelines 2004

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