A Bedside Decision Tree for Use of Saline With Endotracheal Tube Suctioning in Children.

BACKGROUND: Endotracheal tube suctioning is necessary for patients receiving mechanical ventilation. Studies examining saline instillation before suctioning have demonstrated mixed results. METHODS: A prospective study to evaluate whether saline instillation is associated with an increased risk of suctioning-related adverse events in patients 18 years old or younger requiring mechanical ventilation through an endotracheal tube for at least 48 hours when suctioned per protocol using a bedside decision tree. RESULTS: A total of 1986 suctioning episodes (1003 with saline) were recorded in 69 patients. The most common indication for use of saline was thick secretions (87% of episodes). In 586 suctioning episodes, at least 1 adverse event occurred with increased frequency in the saline group (P < .001). Normal saline was more likely to be associated with hemodynamic instability (P = .04), bronchospasm (P < .001), and oxygen desaturation (P < .001). Patient factors associated with adverse events include younger age (P < .001), a cuffed endotracheal tube (P = .001), endotracheal tube diameter of 4.0 mm or less (P < .001), respiratory or hemodynamic indication for intubation (P < .001), underlying respiratory disease (P < .001), and longer duration of mechanical ventilation (P < .001). Saline instillation (P < .001), endotracheal tube size of 4.0 mm or less (P = .03), and comorbid respiratory diseases (P = .03) were associated with an increased risk of adverse events. CONCLUSIONS: Saline instillation before endotracheal tube suctioning is associated with hemodynamic instability, bronchospasm, and transient hypoxemia. Saline should be used cautiously, especially in children with a small endotracheal tube and comorbid respiratory disease.

Using simulation to investigate the impact of hours worked on task performance in an intensive care unit.

BACKGROUND: Past studies have indicated a positive correlation between shift length and the rate of medical errors. In situ simulation is an innovative way to study issues in quality of care. OBJECTIVES: To explore the use of in situ simulation as an investigative method by using it to examine the effects of work length on completion rate of and accuracy at critical care nursing tasks. METHODS: Participants were drawn from the nursing staff in the pediatric intensive care unit and were assessed by using a high-fidelity pediatric simulator 3 times during a 12-hour shift. Data recorded included demographic information, time to task completion, and number of steps correctly performed per task. RESULTS: Twenty-eight nurses with a mean of 5.5 years of experience participated. Each nurse cared for a mean of 1.4 patients per shift. A significant decrease (P < .001) of 5.5 minutes was noted in mean completion time across assessment intervals (from 17.9 to 13.3, to 12.4 min). No significant changes in accuracy were noted. Some accuracy issues seemed attributable to simulation artifact, whereas the use of simulation enabled greater standardization in other aspects of the study. CONCLUSION: Critical care nurses take significantly less time to complete tasks at the end of their shift than at the beginning. This, coupled with a lack of change in accuracy of task completion over time, suggests that nursing performance of simple tasks may improve over the course of a 12-hour shift. Simulation can be an effective means to address some quality improvement issues.

Using simulation to address hierarchy-related errors in medical practice.

OBJECTIVE: Hierarchy, the unavoidable authority gradients that exist within and between clinical disciplines, can lead to significant patient harm in high-risk situations if not mitigated. High-fidelity simulation is a powerful means of addressing this issue in a reproducible manner, but participant psychological safety must be assured. Our institution experienced a hierarchy-related medication error that we subsequently addressed using simulation. The purpose of this article is to discuss the implementation and outcome of these simulations. METHODS: Script and simulation flowcharts were developed to replicate the case. Each session included the use of faculty misdirection to precipitate the error. Care was taken to assure psychological safety via carefully conducted briefing and debriefing periods. Case outcomes were assessed using the validated Team Performance During Simulated Crises Instrument. Gap analysis was used to quantify team self-insight. Session content was analyzed via video review. RESULTS: Five sessions were conducted (3 in the pediatric intensive care unit and 2 in the Pediatric Emergency Department). The team was unsuccessful at addressing the error in 4 (80%) of 5 cases. Trends toward lower communication scores (3.4/5 vs 2.3/5), as well as poor team self-assessment of communicative ability, were noted in unsuccessful sessions. Learners had a positive impression of the case. CONCLUSIONS: Simulation is a useful means to replicate hierarchy error in an educational environment. This methodology was viewed positively by learner teams, suggesting that psychological safety was maintained. Teams that did not address the error successfully may have impaired self-assessment ability in the communication skill domain.

Case and commentary: using simulation to address hierarchy issues during medical crises.

SUMMARY STATEMENT: Medicine is hierarchical, and both positive and negative effects of this can be exposed and magnified during a crisis. Ideally, hierarchies function in an orderly manner, but when an inappropriate directive is given, the results can be disastrous unless team members are empowered to challenge the order. This article describes a case that uses misdirection and the possibility of simulated "death" to facilitate learning among experienced clinicians about the potentially deadly effects of an unchallenged, inappropriate order. The design of this case, however, raises additional questions regarding both ethics and psychological safety. The ethical concerns that surround the use of misdirection in simulation and the psychological ramifications of incorporating patient death in this context are explored in the commentary. We conclude with a discussion of debriefing strategies that can be used to promote psychological safety during potentially emotionally charged simulations and possible directions for future research.

Integrated in-situ simulation using redirected faculty educational time to minimize costs: a feasibility study.

INTRODUCTION: Simulation is an effective teaching tool, but many hospitals do not possess the space or finances to support traditional simulation centers. Our objective is to describe the feasibility of an in situ simulation program model that uses minimal permanent space and "redirected" cost-neutral faculty educational time to address these issues. METHODS: Two pediatric simulators and audiovisual equipment were purchased. Course faculty were derived from a group of physicians and nurses with a percentage work assignment apportioned to education. A portion of this was subsequently redirected toward simulation. After 2 years of operation, faculty were surveyed regarding time devoted to the program. Program growth and quality statistics were examined descriptively. RESULTS: The program supported 786 learner encounters in 166 sessions over 2 years. Simulation hours per month increased over sixfold during that period (P < 0.001). Program initiation cost was $128920.89, with subsequent yearly costs of $11,695. Mean program ratings ranged between 4.5/5 for Crisis Resource Management and 4.4/5 for communication skills training. Resident (2.6 h/y increase, P value <0.001) and nursing (2.2 h/y increase, P < 0.001) simulation hours increased significantly. Faculty involvement averaged between 3% and 32% of total work hours. CONCLUSION: This report demonstrates the feasibility of implementing an in situ simulation program using minimal permanent institutional space and cost-neutral redirected faculty time. This type of programmatic structure is conducive to short- and medium-term growth, is well received by participants, and allows for substantial cost savings. Future work will be needed to determine what growth limitations are inherent in this staffing and structural model.