Impact of Suction-Assisted Laryngoscopy and Airway Decontamination Technique on Intubation Quality Metrics in a Helicopter Emergency Medical Service: An Educational Intervention.

OBJECTIVE: Suction-assisted laryngoscopy and airway decontamination (SALAD) was created to assist with the decontamination of a massively soiled airway. This study aims to investigate the usefulness of SALAD training to prehospital emergency providers to improve their ability to intubate a massively contaminated airway. METHODS: This was a prospective study conducted as a before and after teaching intervention. Participants were made up of prehospital providers who were present at regularly scheduled training sessions and were asked to intubate a high-fidelity mannequin simulating large-volume emesis before and after SALAD instruction. They were subsequently tested on 3-month skill retention. Twenty subjects participated in all stages of the study and were included in the analysis. RESULTS: The median time to successful intubation for all study participants before instruction was 60.5 seconds (interquartile range [IQR] = 44.0-84.0); post-training was 43.0 seconds (IQR = 38.0-57.5); and at the 3-month follow-up, it was 29.5 seconds (IQR = 24.5-39.0). The greatest improvement was seen on subgroup analysis of the slowest 50th percentile where the median time before instruction was 84.0 seconds (IQR = 68.0-96.0); post-instruction was 41.5 seconds (IQR = 36.0-65.0); and at the 3-month follow-up, it was 29.5 seconds (IQR = 25.0-39.0). CONCLUSION: The implementation of the SALAD technique through a structured educational intervention improved time to intubation and the total number of attempts.

The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation: A pilot before-after study.

This study demonstrated a training program of the suction-assisted laryngoscopy assisted decontamination (S.A.L.A.D.) technique for emergency medical technician paramedic (EMT-P). The effectiveness of the training program on the improvements of skills and confidence in managing soiled airway was evaluated.In this pilot before-after study, 41 EMT-P participated in a training program which consisted of 1 training course and 3 evaluation scenarios. The training course included lectures, demonstration, and practice and focused on how to perform endotracheal intubation in soiled airway with the S.A.L.A.D technique. The first scenario was performed on standard airway mannequin head with clean airway (control scenario). The second scenario (pre-training scenario) and the third scenario (post-training scenario) were performed in airway with simulated massive vomiting. The post-training scenario was applied immediately after the training course. All trainees were requested to perform endotracheal intubation for 3 times in each scenario. The "pass" of a scenario was defined as more than twice successful intubation in a scenario. The intubation time, count of successful intubation, pass rate, and the confidence in endotracheal intubation were evaluated.The intubation time in the post-training scenario was significantly shorter than that in the pre-training scenario (P = .031). The pass rate of the control, pre-training, and post-training scenario was 100%, 82.9%, and 92.7%, respectively. The proportion of trainees reporting confident or very confident in endotracheal intubation in soiled airway increased from 22.0% to 97.6% after the training program. Kaplan-Meier analysis revealed that the adjusted hazard ratio of successful intubation for post-training versus pre-training scenario was 2.13 (95% confidence interval of 1.57-2.91).The S.A.L.A.D. technique training could efficiently help EMT-P performing endotracheal intubation during massive vomiting simulation.

Trainees success rates with intubation to suction meconium at birth.

OBJECTIVES: To assess the success rate and main reasons for failure of intubation performed by medical trainees to suction meconium below the vocal cords in non-vigorous infants delivered at ≥36 week gestation. DESIGN: We conducted a prospective cohort study involving 54 residents and nine neonatology fellows in a Canadian level 3 neonatal intensive care unit. Endotracheal intubation to suction meconium was performed using a videolaryngoscope, the video screen being covered during the procedure. All videos were reviewed by two experts blinded to the procedure and to the identity of the trainee. RESULTS: Sixteen videos were available to review between July 2014 and March 2016. Intubation success rate assessed by the reviewers was 6%, compared with 21% as assessed by the trainees. The most common reasons for intubation failure were an improper view of the glottis (87%) and meconium or secretions obscuring the view (67%). 36 % of the time, the trainees identified different reasons for intubation failure than the reviewers. CONCLUSION: Success rate of neonatal intubation to suction meconium was much lower than the success rate reported on infants without meconium. Teaching should be geared towards the most common reasons for intubation failure, possibly using video-based teaching.

Acceptance and effectiveness for learning of a simulation manikin for suprapubic aspiration in toddlers constructed with simple means.

BACKGROUND: Skills trainings are increasing in popularity in undergraduate medical education enhancing clinical competencies and motivation for clinical practice. A suprapubic aspiration (SPA) is the gold standard to obtain urine from toddlers and young infants with fever and unclear focus to prove an urinary tract infection. METHODS: In a blended-learning scenario with virtual patients and skills lab training students were trained for a SPA. Currently, no toddler simulation manikin for SPA is available on the market so we constructed one with simple means. Students' acceptance and their view on relevant aspects of the manikin for learning effectiveness were assessed. RESULTS: With an expenditure regarding work of 3½ h and material costs of 188.12 Euro we were able to construct a paediatric manikin for suprapubic bladder punction using a cheap basic life support manikin. N = 56 students rated their learning success with the manikin as high (77.2 ± 21.6; mean and standard deviation; visual analogue scales from 100 = totally agree to 0 = don't agree at all). The model was rated as useful for training (84.2 ± 17.2) and realistic (62.1 ± 23.5). Important factors for students' learning success were (in descending order) that "urine" could be aspirated (81.4 ± 19.5), the feel of the needle inserted in the manikin (71.5 ± 23.2), and--notably less important--the outer appearance in general (40.3 ± 24.6). CONCLUSIONS: We present a construction of a paediatric manikin for suprapubic aspiration with simple means for a realistic learning scenario with high learning success.

Using a laryngeal tube suction-device (LTS-D) reduces the "no flow time" in a single rescuer manikin study.

BACKGROUND: In 2005, the European Resuscitation Council and the American Heart Association published new guidelines for Advanced Life Support. One of the points was to reduce the time without chest compressions in the first phase of cardiac arrest. OBJECTIVE: We evaluated in a manikin model whether using the single-use laryngeal tube with suction option (LTS-D) instead of endotracheal intubation (ET) and bag-mask-valve ventilation (BMV) for emergency airway management could reduce the "no-flow time" (NFT). The NFT is defined as the time during resuscitation when no chest compressions take place. METHODS: A randomized, prospective study was undertaken with 150 volunteers who performed management of a standardized simulated cardiac arrest in a manikin. Every participant was randomized to one of three different airway management groups (LTS-D vs. ET vs. BMV). RESULTS: The LTS-D was inserted significantly faster than the ET tube (15 s vs. 44 s, respectively, p < 0.01). During the cardiac arrest simulation, establishing and performing ventilation took an average of 57 s with the LTS-D compared to 116 s with ET and 111 s with the BMV. Using the LTS-D significantly reduced NFT compared to ET and the BMV (125 s vs. 207 s vs. 160 s; p < 0.01). CONCLUSIONS: In our manikin study, NFT was reduced significantly when the LTS-D was used when compared to ET and BMV. The results of our manikin study suggest that for personnel not experienced in tracheal intubation, the LTS-D offers a good alternative to ET and BMV to manage the airway during resuscitation, and to avoid the failure to achieve tracheal intubation with the ET, and the failure to achieve adequate ventilation with the BMV.

A structured course teaching junior doctors invasive medical procedures results in sustained improvements in self-reported confidence.

Pressure on working hours has led to a decrease in opportunities for training in invasive medical procedures for junior doctors. The effect of a structured course on immediate and medium-term changes in self-reported confidence was investigated. A one-day model-based practical course was run on two separate occasions teaching central venous line placement, lumbar puncture, Seldinger-technique chest drain insertion and knee joint aspiration. Attendees were asked to indicate their confidence in each procedure on a 10-point Likert scale before, immediately after and three months after the course. Significant improvements in self-reported confidence were seen for all procedures which were sustained at three months. Feedback was universally positive. Practical preclinical training may be a useful adjunct to patient-based training in invasive procedures. The course was particularly popular with foundation year trainees: ideally this training should be available before trainees' first exposure in the clinical setting.

The training, experience, and confidence of junior doctors in performing pleural procedures.

AIM: Pleural procedures may cause patient discomfort and serious complications if performed inadequately. We surveyed junior doctors to provide information about training and experience. METHODS: We surveyed 493 junior doctors working in departments involved in pleural procedures in three teaching hospitals via postal questionnaires in 2002. RESULTS: The response rate was 66%. Formal training in the performance of pleural procedures was limited at undergraduate and postgraduate levels. Theoretical training at postgraduate level in pleural aspiration, chest drain insertion, and closed pleural biopsies was reported by 34%, 40%, and 14% of respondents respectively. Practical training using animal or artificial models occurred infrequently. Pleural aspiration, chest drain insertion, and pleural biopsy had been performed at least once by 91%, 66%, and 41% of respondents respectively. Most doctors felt they needed more training in chest drain insertion and pleural biopsy. Confidence in performing procedures was related to the number of times the procedure had been performed but not to formal teaching. CONCLUSIONS: This study provides a comprehensive survey of the background training, experience and confidence levels of junior medical staff in performing pleural procedures. Training in pleural procedures was limited and our results suggest the need for better training programmes and supervision of junior doctors.

Evaluation of an educational intervention to promote breast pump use among women with infants in a special care nursery in Kenya.

OBJECTIVES: Development of an educational program for women of special care nursery (SCN) infants in Kenya about the use and cleaning of breast pumps through culturally appropriate teaching tools as well as conduction of an evaluation of change in knowledge, attitudes, beliefs, and practical ability in pump use following the educational intervention. DESIGN: An evaluation of an educational intervention. SAMPLE: 40 women with infants in the SCN unable to directly breastfeed. INTERVENTION: Educational intervention instructing electric or pedal breast pump use and cleaning with a pre- and posttest evaluation. RESULTS: Paired t test scores of the combined practically oriented questions were significantly increased from 1.8 to 4.6 (p<.001) from pre- to posttest scores. Likewise, the practical demonstration of learned pump use skills significantly improved from 0.08 preintervention to 4.8 postintervention ( p<.001). CONCLUSIONS: Results of the evaluation indicated the intervention significantly increased women's practical knowledge regarding use and cleaning of the breast pump and accessories. With knowledge of proper use of breast pumps, women will be more likely to successfully utilize pumps to provide adequate milk volumes for SCN infants. A culturally appropriate educational intervention in developing countries appears to be a feasible means of facilitating instruction of breast pump use.

Effect of performance feedback on tracheal suctioning knowledge and skills: randomized controlled trial.

AIM: This paper is a report of a study to determine whether individualized performance feedback improved nurses' and physiotherapists' knowledge and practice of tracheal suctioning. BACKGROUND: Nurses' knowledge and practice of tracheal suctioning is often deficient. Whilst teaching has been shown to improve suctioning knowledge and practice, this is not sustained over time. METHOD: Ninety-five qualified healthcare professionals (nurses and physiotherapists) in two acute hospitals were randomly allocated to receive either individualized performance feedback or no additional feedback after a standardized lecture and practical demonstration of tracheal suctioning. Randomization was stratified by profession, seniority and site. Data were collected in 2005 in a clinical setting involving patients and a simulation setting. The outcome measures were knowledge and practice of tracheal suctioning, assessed by self-completion questionnaire and structured observation. RESULTS: In both settings, intervention groups performed statistically significantly better in terms of knowledge (P = 0.014) and practice (P = 0.037) at final follow-up. Those who received performance feedback had statistically significantly higher knowledge (P = 0.004) and practice (P < 0.01) scores than the control group. For practice, there was also a relationship between professions (P < 0.01), with physiotherapists performing better than nurses overall, and an interaction between group and setting (P < 0.01), with performance feedback showing a stronger positive effect in the simulation setting. CONCLUSION: Retention of knowledge and tracheal suctioning practice is improved when training is followed up by tailored feedback on performance. Further research would shed light on how long such improvements are sustained, and whether the improvements seen in a simulated setting can be generalized to clinical settings.

Birth to breast--a feeding care map for the NICU: helping the extremely low birth weight infant navigate the course.

Breast milk has been shown to contribute significantly to positive neurodevelopmental and medical outcomes in the extremely low birth weight (ELBW) infant population. It is crucial that ELBW infants receive their mother's colostrum as a first feeding, followed by expressed breast milk for as long as possible. Evidence-based literature supports the difficult challenges both mothers and ELBW infants face if they are to succeed at breast pumping and breastfeeding. Influencing factors include the medical fragility of the infant, limited frequency and duration of kangaroo care between mother and infant, lack of an adequate volume of breast milk, as well as inconsistent or incorrect information surrounding the use of breast milk and breastfeeding. A feeding care map as described in this article can help the bedside nurse assist the mother-ELBW infant dyad in optimizing breast milk volumes, laying the groundwork for breastfeeding. Displaying supportive practices and preterm infant developmental milestones, the map categorizes infant, maternal, and dyad feeding issues along a progressive time line from admission to discharge.

Influence of airway management strategy on "no-flow-time" during an "advanced life support course" for intensive care nurses - a single rescuer resuscitation manikin study.

BACKGROUND: In 1999, the laryngeal tube (VBM Medizintechnik, Sulz, Germany) was introduced as a new supraglottic airway. It was designed to allow either spontaneous breathing or controlled ventilation during anaesthesia; additionally it may serve as an alternative to endotracheal intubation, or bag-mask ventilation during resuscitation. Several variations of this supraglottic airway exist. In our study, we compared ventilation with the laryngeal tube suction for single use (LTS-D) and a bag-mask device. One of the main points of the revised ERC 2005 guidelines is a low no-flow-time (NFT). The NFT is defined as the time during which no chest compression occurs. Traditionally during the first few minutes of resuscitation NFT is very high. We evaluated the hypothesis that utilization of the LTS-D could reduce the NFT compared to bag-mask ventilation (BMV) during simulated cardiac arrest in a single rescuer manikin study. METHODS: Participants were studied during a one day advanced life support (ALS) course. Two scenarios of arrhythmias requiring defibrillation were simulated in a manikin. One scenario required subjects to establish the airway with a LTS-D; alternatively, the second scenario required them to use BMV. The scenario duration was 430 seconds for the LTS-D scenario, and 420 seconds for the BMV scenario, respectively. Experienced ICU nurses were recruited as study subjects. Participants were randomly assigned to one of the two groups first (LTS-D and BMV) to establish the airway. Endpoints were the total NFT during the scenario, the successful airway management using the respective device, and participants' preference of one of the two strategies for airway management. RESULTS: Utilization of the LTS-D reduced NFT significantly (p < 0.01). Adherence to the time frame of ERC guidelines was 96% in the LTS-D group versus 30% in the BMV group. Two participants in the LTS-D group required more than one attempt to establish the LTS-D correctly. Once established, ventilation was effective in 100%. In a subjective evaluation all participants preferred the LTS-D over BMV to provide ventilation in a cardiac arrest scenario. CONCLUSION: In our manikin study, NFT was reduced significantly when using LTS-D compared to BMV. During cardiac arrest, the LTS-D might be a good alternative to BMV for providing and maintaining a patent airway. For personnel not experienced in endotracheal intubation it seems to be a safe airway device in a manikin use.

An observational study on the open-system endotracheal suctioning practices of critical care nurses.

AIM AND OBJECTIVES: The purpose of this study was to investigate open system endotracheal suctioning (ETS) practices of critical care nurses. Specific objectives were to examine nurses' practices prior to, during and post-ETS and to compare nurses' ETS practices with current research recommendations. BACKGROUND: ETS is a potentially harmful procedure that, if performed inappropriately or incorrectly, might result in life-threatening complications for patients. The literature suggests that critical care nurses vary in their suctioning practices; however, the evidence is predominantly based on retrospective studies that fail to address how ETS is practiced on a daily basis. DESIGN AND METHOD: In March 2005, a structured observational study was conducted using a piloted 20-item observational schedule on two adult intensive-care units to determine how critical care nurses (n = 45) perform ETS in their daily practice and to establish whether the current best practice recommendations for ETS are being adhered to. RESULTS: The findings indicate that participants varied in their ETS practices; did not adhere to best practice suctioning recommendations; and consequently provided lower-quality ETS treatment than expected. Significant discrepancies were observed in the participants' respiratory assessment techniques, hyperoxygenation and infection control practices, patient reassurance and the level of negative pressure used to clear secretions. CONCLUSION: The findings suggest that critical care nurses do not adhere to best practice recommendations when performing ETS. The results of this study offer an Irish/European perspective on critical care nurses' daily suctioning practices. RELEVANCE TO CLINICAL PRACTICE: As a matter of urgency, institutional policies and guidelines, which are based on current best practice recommendations, need to be developed and/or reviewed and teaching interventions developed to improve nurses' ETS practices, particularly in regard to auscultation skills, hyperoxygenation practices, suctioning pressures and infection control measures.

Influence of an interactive joint model injection workshop on physicians' musculoskeletal procedural skills.

OBJECTIVE: To assess the effect of an intervention workshop designed to improve intraarticular (IA) and periarticular (PA) injection skills among primary care physicians. METHODS: An interactive joint model injection workshop was designed for family practice and internal medicine residents and faculty, aimed at improving their skill performing IA and PA procedures. The workshop covered indications, contraindications, complications and supplies required to perform procedures, formulations of steroidal preparations, volumes used for injection, skin preparation, method of needle insertion, synovial fluid aspirations, aftercare, and processing of the synovial fluid. Interactive prewired models of shoulders, wrist, hand, knee, ankle, and foot provided feedback with an audible buzz for correctly performed procedure. A survey was administered immediately following the workshop and after 10 months. RESULTS: Of 60 participants, 39% were residents and 21% faculty. The mean age (+/- SD) of participants was 32.7 +/- 7.7 years. The mean duration of followup was 10.5 months. The mean +/- SD comfort scores on theoretical and practical aspects of the procedures surveyed prior to the workshop were 4.8 +/- 2.5 and 4.4 +/- 2.5, respectively; and after the workshop were 8.0 +/- 1.7 (p = 0.001) and 7.8 +/- 1.7 (p = 0.001), respectively. The mean change in comfort scores in practical aspects of IA and PA procedures did not correlate with the age of participants, but rather with their training/faculty status (p = 0.01). The mean changes in comfort scores with practical aspects of these procedures were highest among first-year residents (4.5+/- 2.1), followed by faculty (3.1 +/- 1.7). On followup, the mean comfort scores on theoretical and practical aspects of the procedures were 6.3 +/- 1.7 and 6.0 +/- 1.8, respectively, significantly higher than the pre-workshop scores (p = 0.03, p = 0.02). CONCLUSION: Joint injection workshops using interactive joint models can improve the comfort scores of physicians learning IA and PA injection skills, in both theoretical and practical aspects of the procedure. Faculty and first-year residents in training seem to benefit the most; significant improvement in comfort scores was seen across the spectrum of physicians. Thus acquired comfort with knowledge and practical aspects of joint procedures may undergo attrition over time; however, significant residual benefits are still appreciable over time.