Traditional Poster Round
In 2017, Texas Children’s Hospital – The Woodlands (TCH-TW) opened for inpatient services, offering 24-hour onsite services with the exception of certain subspecialties including pediatric anesthesia and otolaryngology who are on call offsite during nights, weekends, and holidays. We identified the emergent presentation of a patient with a critical airway (inability to orally intubate with standard laryngoscopy) and respiratory failure after hours as a latent safety threat (LST) to our facility. A multidisciplinary team of key stakeholders adapted an existing “difficult airway algorithm” for our campus and performed simulation based systems testing exercises with the goal of minimizing the time from identification of an airway emergency to arrival of airway experts and equipment to the bedside.
A multidisciplinary workgroup was formed with representation from pediatric anesthesia, otolaryngology, intensive care, emergency medicine, nursing, and simulation. The “difficult airway algorithm” from Texas Children’s Hospital – West Campus was adapted for use at TCH-TW and posted in key areas of the Emergency Center (EC) and Pediatric Intensive Care Unit (PICU.) The workgroup created clinical scenarios based on identified testing priorities. The first simulation based clinical systems testing (SbCST) was held in the Emergency Center as a patient with a “critical airway” presented in respiratory failure. Next, the workgroup simulated a “difficult airway” (difficulty with adequate visualization of the glottis with standard laryngoscopy) in the Pediatric Intensive Care Unit that escalated to a “critical airway.” Failure Modes and Effects Analysis was performed and the workgroup made recommendations following each exercise. The final algorithm was approved and a brief presentation was prepared and assigned to the appropriate personnel via an online educational module. The final systems testing exercise was held in the outpatient Sleep Laboratory with an unanticipated respiratory event in a patient with a known critical airway.
A total of 8 LSTs were identified after the SbSCT in the EC. The participants identified key improvements to the notification process. When the exercise was modified and repeated in the PICU, 5 LSTs were identified. The LSTs included the availability of the surgical airway cart with advanced airway equipment, staff familiarity with the algorithm, appropriate notification of key personnel, and equipment failure with a hospital use phone. Appropriate faculty and staff received training on the airway algorithm. An additional surgical airway cart was purchased in order to maintain a cart in the EC and PICU.
During the algorithm evaluation period, the hospital experienced actual testing of the airway algorithm which also shaped the final product. This multidisciplinary effort also allowed for the outpatient Sleep Laboratory to undergo an expansion in scope of practice to perform polysomnograms on a patient with a stable tracheostomy and critical airway.
Our project exemplifies the importance of multidisciplinary systems testing in a community hospital without 24-hour onsite pediatric anesthesia or otolaryngology coverage to avoid airway related serious safety events. In addition, this endeavor permitted the safe expansion in scope of practice for our community hospital Sleep Lab which improves access to care.
Key words: systems testing, latent safety threats, community hospital