Dr. Brian Miller: Airway CQI Program (4/25/2023)

Is that okay with you?

Yeah.

Hey, quick question, Angus. Are you able to do that presentation you're going to do about the IDing where ODs are?

We were just talking about that. No, I think I'm going to get called away right about 3:30 here. Unfortunately I'm going to leave this stream up. But I was just talking to Peter about is the afternoon time isn't working out as good for me.

Okay, got it. Okay. Yeah, I'm gonna have a conversation about that. We may want to switch back over to the other one if that's the case. How are we doing on this end, Peter? We look like we get more people coming out or about the same?

I would say about the same. Yeah.

Okay, so I may. We'll talk about later because I want to hurt you either if it's working out for you. But yeah, I think maybe, maybe we'll.

Make the switch after Eagles. Right? I'll do that.

Yeah, yeah, yeah. I don't like to keep switching things around.

Yeah.

But yeah, survey there and we'll see if we can get a better handle on it.

Yeah, perfect. Okay.

Okay for us to take care of our little business here. Yeah, thanks.

Okay. You're welcome.

All right.

Well everyone welcome. It's Tuesday again. It seems like Tuesdays come up very frequently nowadays. It's three o' clock on the East Coast. I'm very, very excited about today's guest. The minute I saw Brian speak about this at the nmsp, I came up to him and was like, that was probably one of the best talks I've ever heard. As someone who likes cqi, as someone who loves innovation and loves the quality behind innovation, Brian is somewhat of a guru at not just the implementation but also the cqi. I asked him to come on today. For many of you who don't know, he's from the Dallas Fort Worth area. He's an EMS medical director and ED physician.

And I wanted him to come on to talk about his airway CQI process. So without any further ado, Dr. Brian Miller, thank you so much for joining us and take it away.

Thank you, Peter and I really appreciate both the kind words and the invitation for being on here. So just quick make sure I can actually advance slides here. Yeah, perfect. Okay. So first off, you know, I'm only one of many of our team really. The credit has to go to, you know, our entire office of medical director for the work work on this. I just happened to put the slides together and be the mouthpiece for what's really a great team behind all this. And so, as Peter said, I'm one of the associate systematical directors over in the office of medical director for the MAMS, better known as the MedStar system, and then also happened to do some work with Dallas Fire as one of their deputy medical directors as well. And so, so really we wanted to talk about the video laryngoscopy recordings and really how we adapted that into intubation education and our overall clinic quality management. So I have no conflicts of interest for this talk. I don't make any money from any device manufacturers. And so I will mention the specific name of our device only just for frame of reference of what we're using for our processes. But again, I don't have any specific allegiance to any brand or any money command for any of that. So really when you think about intubation as the process, especially, you know, when you think of direct laryngoscopy or non recording VL devices, it's really a black box. We do some kind of input and then there's an output and really the process in the middle. And what the inner workings of that process are, are really a mystery short of what we can gain off of a monitor file and things like that. And so really we go from a decision to intubate, some stuff happens and then at worst we have just a electronic PCR saying successful or unsuccessful, and we really lose everything in that middle part of the process that goes on. And so this is why, part of the reason we wanted to move to video laryngoscopy, especially with recordings, to kind of define this process a little bit further. And so we want to take that question mark out of that and open the box and really figure out what, how do we do this better and get really dig down into the quality management, quality improvement aspect of airway management and intubation. So the goals that I really wanted to kind of put together for this talk were that we wanted to define the procedural and the event review advantages of implementing VL into a system, describe our implementation in our system, and then really discuss how we use this in that quality management program in some areas for how we use these for initial and continuing education as well. So we use a lot of different tools already in our, you know, medical direction, quality improvement aspects. Right? We have, you know, our biometrics from our monitor files, whether that be a LifePak, a Zol Phillips, whatever. We already have those and many of us look at those for, you know, whether the CPR performance was adequate or not. Was there any title on this intubation or not. You know, some of us are also using audio at times on the monitors. And then, you know, certain systems have used body cams. And then you look into the hospital a little bit and you know, trauma teams are using video in the ED to evaluate their performance and opportunities for quality improvement. So really, video laryngoscopy with recordings is an exact thing that we would want to use similar to all these other devices there. So a little bit about our system. We're about 174,000 calls for service per year. We do both non emergent and emergent transports for the city of Fort Worth as well as 14 other outlying cities. And so we also do have first response from our first responder organizations, which are primarily fire departments. And then we do ALS transport with a paramedic and an EMT and also have some BLS units as well. So on our average, we're doing about 750 intubations a year. So we're fairly high frequency intubation service with a lot of critical patients and then overall view lumping, SupraGlassic Airways and BVM. We're doing about 2,000 airway management cases a year and review each of those already in our continuous quality improvement processes and reviewing all cardiac arrest and intubation. So again, there's a pretty big impetus for us at nvl. So then Covid hit and you know, when there was all these discussions of air stalling procedures, you know, securing the airway, you know, getting our providers back off of the face, you know, all the PPE stuff, this really just kind of accelerated our process to get on board with vl. And so we ultimately chose the UE scope for multiple reasons. Primarily is that we have a lot of ALS providers on our system. We run 50ambulances and have a number of ALS FROs. And so we were purchasing a fairly large volume of these devices, you know, upwards of 80 devices. So really economics and durability and all those things really came into play. And ultimately the uescope was one that when we trialed it ended up being the best. And so here's our actual RFP and some of the specifications right there. And so really before we even got into the request for proposal process, we had already previously stated that it had to have video recording. And then we're a big human factors believers. And so we really wanted to take the human factor out of that and have an automatic video recording device. That way no one had to remember to press a button to get the recording in order. And so but the floor of RFP was really just to even have video there. And so we ended up implementing VL in right in August, July and August of 2020. So we've had a fair bit of experience. And so we actually implemented this basically in our protocol cycle and with a cadaver lab where all of our ALS providers were able to get in there and get hands on with the device, we really broke up the specific intubation techniques that we did and then subsequently implemented the device and began kind of our quality improvement monitoring. And so one of the other key aspects of this was kind of when we were rolling this out is how do we get these files off of the device onto the computer? And so we chose a hard connection basically to use the USB device directly into a dedicated computer. We only have two deployment sites. And so as crews are coming in and out of those sites, it was a natural, logical place for them to be able to hook up and drag and drop the files. And so you can say essentially all of my files right there, basically where I can get on my computer and look at any of these files from, you know, the previous months or days of intubation. I think what, as we've learned and spoke with other teams as well, you know, a cloud based solution for this, where crews can hook into their tablet and basically fill out a form that can designate a run number for some of these things is also fairly beneficial. And so we actually are considering changing our process in that way to a little bit more of a cloud based solution rather than a hard hookup to the computer every time. Again, our device does require the USB though. And so then as far as our quality management goes, you know, with every implementation we saw, you know, kind of that initial period where we were not very satisfied with our intubation rates and actually took a dip from our previous direct laryngoscopy numbers. And so at the same time, kind of the NEMSP's position statements on their recompendium were coming out and you know, there was all the recommendations that we were doing a lot of already, which was both the subjective and the objective data elements. And so we already had a lot of kind of subjective things about airway success and failure and then all of our objective metrics such as, you know, hypoxia and pre oxygenation and all those things, we really wanted to kind of start measuring some additional of the, you know, the process measures and as well as the outcome and balancing measures we had done before. And so we use all these findings to kind of just Tailor our our implementation approach as well as some of our ongoing education similar to other things. And so this is the list from the Airwick compendium of all the different data you could pull. And so when you really look at video layering gossipy recording data elements and where that really comes into play, that wasn't really covered in the area compendium position statement was really the intubation technical factors that unknown that we talked about earlier. And then more of the objective review. The time of attempt. Was there actually a single attempt or was this multiple attempts captured on video? The actual success by video? And then you know, other things such as the grade of view. Was there difficulty and complications, you know, was this a contaminated way or not? And so we got to get all these unlocked as soon as we got our video on there. And then I thought this was a really interesting paper. It was actually placed in the Society for Academic Emergency Medicine and there was Barnacle Bracey and many of us know Scott Weingart from McRIT and they really defined out three performance areas during the phases of intubation and the errors that are behind it. As we know that it's really just an series of incremental micro skills that goes into intubation. And so the use of the video laryngoscopy could let us evaluate each of these different components right there. And so there's really the errors of insertion of the blade and actually getting past the tongue and identifying structures. Then actually how you get and kind of manipulate your final view and then the actual tube delivery. And so this is kind of what our experience was as we watched countless videos. I was essentially almost watching them daily when we first rolled them out. And so this is an example of one of the recordings right here that we obtained. And I'll just kind of walk you through. So you see this is a cardiac arrest airway. You can see essentially just a ton of contamination down there. The intubator gets a little bit lost on the right side for a second. A little bit of delayed suction coming in to view. Just kind of watching all that slosh around. So it's sent periods that they may not have prepped suction ahead of time as we would have liked them to. And so they're kind of hanging out here for a second and. And eventually we are going to get our view. And then with suction. So here we are. And so the UE scope is a little bit of a hyper angulated device. And so this very, very deep view. You can see there's no epiglottis there or anything like that. And basically they're hunting and pecking with the bougie here. And ultimately this is an unsuccessful airway. And so we were able to kind of guide the crew through that. Hey, this was airway that definitely needed suction, perhaps even, you know, continuous suction with a salad technique. Hey, you were a little bit deep on this one. And this is probably your issues for the bougie because in reality all their chart said was difficulty passing the bougie and ultimately an unsuccessful airway. And through the review of the video, we were able to guide that crew right there. And so that was our feedback to the crew. But really, you know, the, the biggest key I could say is that our crews are able to immediately review their video after the call on the device, whether at the hospital. And you really see a lot of the time that they're kind of all huddled around, you know, as they're kind of cleaning up the back of the truck after a call, watching the video, kind of critiquing and giving, you know, feedback to each other. And I think that's probably one of the best things there. That way you don't have kind of that negative connotation when, you know, a medical director comes in to provide, you know, some guidance and feedback. This is all kind of peer driven feedback, if not just self driven feedback as well, which I think is really invaluable in some of that part. And then of course, as we're doing case reviews for either, you know, the intubation, performance improvement or some other aspect, a lot of time we can bring up these videos as well and you know, and discuss these with the crew. And a lot of time we find is they've already done some debrief already internally and you know, we can just give them the finer points along the way. But to be able to bring up on a big screen, you know, the video there and share it and go through step by step pause and you know, take this out of the real time and, and go through has been really a great perspective as well. As you can see here. This is a disgusting airway. And so sometimes the videos are actually a little too, too detailed. So be, be be aware when you're eating your lunch. And so.

So really this is all kind of what fed into our quality improvement cycles is we just began to watch all these videos and recognize, you know, that there was system wide issues that we couldn't really tackle this on an individual basis. And so this really came into our plan. Do study, act type cycles. And one of the first components was this was again that individualized feedback which was the intubation feedback report. And so you can see here all the key components. And this was given to each crew afterwards. It's actually a pretty big time set for our team. And so, and we're really providing some of the same feedback. And so we moved on to different things. And so this was actually one of our biggest initiatives, was really a video review series and it was called Tube Talk. And we really went through each of those key aspects of intubation and discussed some of those tips and tricks using real life videos from our crews. You know, the good and the bad and the ugly and allowing them to learn from, you know, each of those aspects along the way as well. We also do host, you know, trainees at our sites as. And so when they come to rotate, you know, many of them have never had experience with RVL device and very limited experience, you know, during their initial training. Some have that exposure to specific devices, but others have not. And so then the other part of this is that many of them also, you know, we need to bridge that experience to skill proficiency gap. You know, the median number of endotracheal encounters, you know, by one study was about seven. But really, you know, I think this is probably an undershoot. But you know, the 20 to 25 endotracheal intubations for a first pass, greater than 90% has been quoted in some of the literature and some of it gone higher. So really having to bridge them from that experience into skills proficiency is a challenge for us. On top of that, where are they training? They're often in the OR for their initial tubes. And so that's that well clean, well prepped, clean airway. And we're putting them out in the wild now where they've really never seen a true epiglottis in the wild or anything else out there. And the reality is this is where they're at. You know, they have that patient who's, you know, drank, you know, two pints of liquor today and is going to regurgitate that up. They're in that back bedroom trying to intubate after they just ate the, you know, Chinese buffet. And you know, we're always having challenging body habitus as well. And so this is really the reality of where our medics are out there, you know, trying to intubate, which makes it even more challenging when they're, you know, doing their initial training in the or. And so really we wanted to give them an avenue where we can coach performance of those errors in real time. Having, you know, that field training officer, that mentor out there to assist them along the way to get that muscle memory of that successful intubation, allowing them again to do that self reflection or that instructor debrief, whether that be on a mannequin or a real individual. And then even more so is giving them video review prior to even going out of some of those tube top principles that from our video review series and giving kind of a condensed version of that, of the absolute essentials and really giving them a feel of what they're actually going to experience once they get out there. And so this is really that field conditions teaching we talked about. We also do use this during continuing education as well. We've used videos and kind of given specific examples and kind of drilled those during some of our cadaver lab trainings and other things. And then I'm really a big believer in this quote right here, which is really that once you reach that acceptable skill level, which we would like to believe most of our medics have achieved that by the time they get, you know, through our credentialing process or continuing that skill refinement, the fact is that really just keep on doing the same thing over and over and more. Experience itself does not really lend to anything. It's really the deliberate practice that goes. And so this is from the NMSP position statement on basically every management training and education. And really this is where I believe VL can also come in, is that we have well defined goals, we have things and steps along the way that we want them to model that behavior. And then we give them that evaluation for that self evaluation and that opportunity for feedback from others, whether that be peers or others. And then, and then also give them some of those challenging situations as well where they have to problem solve. So not all of our medics are going to see a heavily contaminated bloody airway where suction is not enough and they need to move on to something else. Not all of them will see a true foreign body airway obstruction or a burn airway. And so allowing exposure to them through these videos, they can continue that problem solving, that repetition and kind of building their airway repertoire as they go. And so this really kind of fits in with those principles we talked about.

So some of your considerations when you actually think about implementing VL is the device selection. You know, we had to balance, you know, having to get a large number of these devices and, and deploy them out there. Our system is generally, you know, more novice intubators so having, you know, a large variety of different blades that they could select from, from we wanted to kind of condense that down. But each system is going to, you know, have different budgets and different abilities to select them. There's also, you know, you know, the question of whether you upload this to the EPCR versus you do a QA QI protected database where you know, you can't go into the EPCR and just immediately pull up this VL file. We actually went with the QA QI protected database because really, you know, for airway confirmation we're going to go with end tidal CO2 anyway. So we didn't really need to expose that video to the EPCR and really just use this for our quality management improvement processes, uploading processes, you know, depending on your WI FI or all those abilities, file size can do that and transmission can also do it depending on your device. We had to put some policies and compliance around this and then you know, who can access these, who can actually use these and then whether you're going to retain this indefinitely versus have a rolling cycle of wiping these files or, and then also of course which metrics are meaningful for you. Really kind of where I see video learning oscomy going in the future is, you know, I really believe this should be the industry standard for VL devices. That automatic recording capability and really the ease of video transfer should be the gold standard at this point. I think there's so many advantages to this as we talked about that. I think this is something we really do need to implement, you know, kind of wide, widespread, industry wide. The other part of this is that you know, we really should be incorporating these into our quality management processes and education moving forward and getting that to more of a standard process rather than, you know, some of these agencies out there being the outliers still. And the expansion of the evidence is really where we need to go as well. There's very, very limited evidence on, you know, the value of that video review and how it can really improve your processes or not. And then some other cool things are, you know, where do we go with this from a machine learning Many of us have exposed to ChatGPT, you know, there's a lot of computers that can now read videos and so perhaps this is an area where, you know, we can actually have some automation of this as well in the future. So that's kind of my take homes is, you know, let's unmask the unknowns. You know, let's take this from a non binary or from a binary process Successful, unsuccessful and kind of open that box a little bit. We can utilize this in our airway management programs and, you know, inform our quality management activities and help out over initial education, really, you know, assist our individuals into a truly productive system learning. So that's all I got. I'm going to put into the chat right now my slide link. And then. And so.

Yeah, Brian, that was, that was incredible. Thanks for doing it. And you know, in the amount of time that was tough to do. I appreciate it. I have a few questions right out of the gate and I'm hoping others do as well and they can just raise their hand. We'll get them in. Which is my question, is the Tube Talk videos, I think are a fantastic idea. Are those available for others to watch or is that internal?

We've kept them internal to this point. You know, we've been working with our legal and this has been a kind of a big thing of. Right. We can cut it off essentially as you go in for, you know, past the teeth, there's really no patient identifying features to an airway, especially as you scrub the dates and, you know, some of the context. So we've been working through with our legal for a while now on just kind of where, what level of de. Identification it would take to kind of share externally. And so we've been sharing with kind of select and select, you know, teams, but really haven't put it out on the. The widespread web yet.

I'm greatly appreciative to Maya Dorset. She's at least given me a nudge to try and get some of this on the Prodigy at some point. And so if we can get it out there, I would love to really share this with, you know, for the greater good. A lot of heart and love went into that from our entire team and you know, for those out there, I'd really love to share it too. But thanks for the question.

Yeah, absolutely. The other question I have for you is as far as what is the time commitment that you're spending? Is it the inhibition goes down, let's say now.

When is the actual medic reviewing it? When are you reviewing it? And then do you have like a quarterly review of all airways? Like what is your sequence there?

So our process for a long time, we've always reviewed anything with positive pressure, cpap, BVM and above. We've always reviewed those in cardiac arrest. And, you know, we are blessed to have a lot of resources where we have a dedicated staff member who already does those reviews. And so from the medic perspective, you know, they do the intubation and most of them immediately post call or reviewing it right there prior to the upload. And so I think that's an area where we would like to really allow that bidirectional where. Oh, I didn't, I just got another call. How can I look at this in the future after I uploaded? And I think that's an opportunity for improvement.

Are they reviewing the call right on the device?

Yeah, they're doing it actively on the device right there, which has playback, fast forward, backward capability.

Okay.

How long did it take from the moment that you started this process until you started seeing a difference? And did you see a first pass success difference? You know, sans hypoxia, et cetera? How long did it take until you saw the value of this QA process?

So we, I think what we saw initially is we had that dip in innovation success initially, and then we tried a lot of that individualized part. And I think what was probably one of the defining things was Tube Talk really addressing things that were unknown to us even prior to deployment of kind of some of those common themes that we really needed to hone in on. And so once we implemented Tube Talk, we definitely saw a rise in success. I think we've had some of the similar challenges a lot of organizations have had, you know, throughout Covid and you know, into present day, of staffing and turnover, you know, for high, high volume services. And so it sometimes feels like we're at Groundhog Day as far as some of that intubation. And so this is kind of an ongoing kind of quality improvement. I saw at least one hand up there, and I know, I see Dr. Pepe does as well.

Yeah, go ahead, Dr. Lee, go ahead.

Say, Brian, can you hear me?

Yes, I can.

Just one question. Can you just make some comments about.

This program, if you will, and maybe the use of the VL in the context of your utilization of bridge devices and which ones to use?

Help me understand Bridge devices. Are you talking supraglottics or what are you talking.

Yeah, superglottic.

Okay. Okay. So we have allowed intubation and supraglottics and cardiac arrest for better or worse, for, for the time. And then we have a drug assisted airway management program with ketamine. And then our critical care paramedics have always carried paralytics. And so. So that's some of the things actually we've been able to identify through our system is we've always been, you know, for the most part, for most of our medics, a Ketamine only, you know, kind of sedation only intubation, you know, for perceived safety initially. And really through our implementation of vl, it's allowed us to recognize that that's probably not as ideal as we could have thought and.

What was previously DL and you could, you know, blame it on a host of different things really allowed us to hone in on all that. And so we've always allowed superglottics, whether it be first line or second line. And then, you know, certainly we've encouraged a limitation of number of attempts during cardiac arrest.

And so currently you're not using lytics?

We do not. For the vast majority of our intubations. We do not. I think you would see if you looked at us a year from now we, we're probably going to be moving towards that.

Great questions, Dr. Pepe.

Yeah, so two things. One is.

I got to get over the other call. But the main one question is that since you're working with legal, right, you won't get an answer for another four years.

That's one.

And then two.

One of the things I was really curious about, you went through the RFP and you had a lot of people look at it and they like this one. Okay, what was it that they liked about this one?

Yeah, and so we trialed three different devices. We actually allowed kind of our, our field training officers, our, and our first responder organization, ALS providers to come in and trial the three devices hand head to head. I think we had a channel device, I believe it was air track. We had the glide scope and then the UE scope and you know, it ended up kind of drilling down to, you know, a lot of our medic's preference of, you know, they were having, you know, they were less of a channel fan at the moment. Then they like kind of the simplicity of, you know, whatever. It's four or five different blades rather than, you know, having to choose a standard or a hyper regulated blade. And then, you know, cost was certainly an issue of, you know, the UE scope was found to be fairly economical for us when we were deploying about 80 out there. And so we really had all of them trial in the lab. We had the medical direction, the operational and budgetary side of it weigh in. And then finally right from our medics, we had a survey and allowed them to weigh in on what they liked and what they didn't like and kind of give an overall rating and all that basically compiled into the more objective process that was needed for the rfp.

Okay, got it. I Have to go. So. But if you come out and do it the other side, you got to do it in like about a third of the time, get bullet answers. So thanks.

Thanks a lot.

Bye Bye. Thanks.

Awesome. So, so, Brian, again, really appreciate what I, what I would love for you to leave us with is you have a lot of people on this call who either.

Have a VL program, don't. That, that we don't record. We have the ability to record, but we're not doing the qa. Some people here are probably, you know, doing, doing DL. If, if, if you were, if you were to, you know, if you were the advice giver here and, and somebody here wanted to set up a program kind of. And I know that you've said it, but just want you to kind of recap and say, you know, what are the top three things that people should be looking at? If they're, if they're innovating in the field and if they're using, if they're allowing, you know, innovation, either not with medication assistance or with it.

Yeah, I think, you know, from the implementation side. Right. Get involved in your, you know, procurement processes. Whether you're, you know, a medical director or, you know, one of the leadership positions, get involved with that and advocate for devices that record and ideally those that automatically record. That way you first get your data. Second, if you're, if you have devices that aren't getting it, please turn it on and then start your processes to really review these. And, you know, especially if you're a lower frequency intubation system, this is, you know, only a few minutes a week or a month to really hone in on these processes and give you an invaluable tool to help your medics and also help inform your systems improvement. And then finally is, you know, you, you can't improve unless you measure. And so, you know, consider, you know, getting that whole picture, as you mentioned earlier, of, you know, first pass success with hypoxia, hypotension and really, you know, work on processes to monitor those as much as possible.

And you guys use the decanter catheter, right?

We do indeed. Yeah.

We recently switched out and we got rid of all the Yang car. So. Awesome. Well, Brian, again, I love this, I love your talk. Please join us next week. We have Casey Patrick who is going to be coming on, talking about, you know, escapades in airway management and ems. So he'll have a couple of very interesting videos. So please join us every Tuesday. I sent you the link to jump on the Zoom with Dr. Pepe. And again, thank you so much for joining us today.

Brian, thanks again for the opportunity. Thank you for everyone who attended. And please reach out directly if you need any other help. Always help. Happy to help, friends.

Awesome. All right. You're the best. All right, Angus. Thank you.