Nasir I. Bhatti

Need for emergency surgical airway reduced by a comprehensive difficult airway program.

BACKGROUND: Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patients lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy. METHODS: We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006). RESULTS: The number of emergency surgical airways decreased from 6.5 ± 0.5 per year for 4 yr before program initiation to 2.2 ± 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006). CONCLUSIONS: A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Pilot testing of an assessment tool for competency in mastoidectomy

To determine the feasibility, validity, and reliability of an evaluation tool for the assessment of competency in mastoid surgery. This study tests the hypothesis that residents of dissimilar training levels differ in their technical performance as measured by this tool.

Development and pilot-testing of a feasible, reliable, and valid operative competency assessment tool for endoscopic sinus surgery.

Background Otolaryngology residency programs are required by the Accreditation Council for Graduate Medical Education to evaluate residents’ operative competency. Many such tools based on the model of objective structured assessment of technical skills (OSATSs) have been developed in other surgical specialties, but no such instruments exist for otolaryngologic procedures except for tonsillectomy. Endoscopic sinus surgery (ESS) is among the most common rhinologic procedure and lends itself to objective evaluation of operative competency. The purpose of this study was to develop and test a new tool for ESS, focusing on feasibility, content and construct validity, and interrater agreement that can be used for such assessment in the operating room and the cadaver dissection course. Methods Faculty input via the modified Delphi technique helped develop the content of a new OSATS-based instrument. The instrument underwent serial improvements based on 3 years of endoscopic sinus surgery (ESS) cadaver courses. All evaluations were used to calculate construct validity while paired observations were used to determine interrater agreement. Regional and national faculty input was incorporated for increasing generalizability. Internal consistency was calculated using Cronbachs alpha. Results A total of 51 assessments were completed for 28 residents who were evaluated by 15 faculty members as they performed ESS on cadavers over a period of 3 years. A high degree of internal consistency (0.99) and feasibility was noted for the instrument, which took 7 minutes to complete. The interrater agreement improved with focused faculty development for the 3rd year of the course. Conclusion Our results and experience suggest that a feasible, reliable, and valid instrument for objective evaluation of operative competency can be developed for ESS. Further experience at other otolaryngology programs and efforts focused on faculty development will be needed to enhance faculty buy-in. The instrument can be used for formative and summative feedback as well as for identifying residents needing remediation.

Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program.

Objective:The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. Design:A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program’s establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. Setting:Single-center, major university hospital. Patients:The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. Measurements and Main Results:The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. Conclusions:An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.

Imaging Quiz Case 1

44-YEAR-OLD man presented with a 1year history of progressive right-sided hearing loss that developed after a syncopal episode during which he suffered blunt trauma to his occiput. He was unconscious briefly and was taken to the emergency department for evaluation. On arrival, he noted complete deafness in the left ear and marked hearing loss in the right ear, with tinnitus bilaterally. At that time, he denied vertigo. The physical examination was significant for hemotympanum in the left ear, with scant blood in the external auditory canal, no cerebrospinal fluid leak, normal facial strength, and a wide-based gait. A computed tomographic (CT) scan showed intraparenchymal hemorrhages in the frontal and temporal lobes bilaterally with associated edema and a right temporal subdural hematoma. Audiologic testing demonstrated profound hearing loss in the left ear and moderately severe sensorineural hearing loss (SNHL) in the right ear, with a speech discrimination score of 96% and a threshold of 60 dB. The patient received a short course of prednisone for presumed right auditory nerve traction, with modest improvement in his hearing. One year after the injury, the patient was referred to our clinic for fluctuating right-sided hearing loss. The patient reported that his hearing loss remained profound in the left ear and was worsening in a stepwise pattern in the right ear. His tinnitus persisted (greater in the left ear than in the right), and anosmia and dysgeusia had developed soon after the fall. He also complained of disequilibrium, which had improved with vestibular rehabilitation exercises. He reported no other syncopal events or neurologic symptoms. He had no significant history of noise exposure. He denied recent use of ototoxic agents and was taking no prescribed medications. The findings of a review of systems were noncontributory, and the results of otoscopy were normal. Audiologic testing showed a sloping moderate to profound right-sided SNHL, with a speech discrimination score of 30% (speech reception threshold, 65 dB); tympanometry revealed no abnormalities. Vestibular testing showed signs of persistent left vestibular hypofunction. The CT scans of the left temporal bone that were obtained immediately after the injury occurred are shown in the Figure. The right side was noted to have an enlarged vestibular aqueduct that was consistent with a congenital variation, but was otherwise normal. What is your diagnosis?

Objective assessment of mastoidectomy skills in the operating room

Objective(s): To determine the feasibility and validity of an objective assessment tool designed to measure the development of mastoidectomy skills by resident trainees in the operating room. Study Design: Prospective longitudinal validation study. Setting: Tertiary referral center and residency training program. Subjects: Otolaryngology residents. Main Outcome Measure: Technical performance as measured over time using Task-Based Checklist (TBC) and Global Rating Scale (GRS) developed for assessment of mastoidectomy skills. Results: Seventy pairs of evaluations were completed on 15 residents, showing strong correlation between both instruments (r = 0.93; p < 0.0001). Our instrument demonstrated construct validity for both TBC and GRS, showing higher scores with increasing surgical experience in otology. Both instruments showed high interitem reliability with Cronbach &agr; coefficients of 0.98 and 0.95 for TBC and GRS, respectively. Regression analysis showed that thinning posterior external auditory canal (p < 0.05) and opening antrum to deepen dissection at sinodural angle (p < 0.05) were the strongest predictors of overall surgical performance. Conclusion: Our assessment tool is a feasible and valid method of evaluating acquisition of mastoidectomy skills in the operating room. It can be integrated into surgical teaching in the operating room and yields information for direct formative feedback.

Technical skills improve after practice on virtual‐reality temporal bone simulator

To assess whether practice on a virtual‐reality (VR) temporal bone simulator improves acquisition of technical skills in mastoid surgery.

Assessment of Operative Competency in Otolaryngology Residency: Survey of US Program Directors

Objectives/Hypothesis: 1) Assess current status of operative competency assessment and feedback among US Otolaryngology residency programs. 2) Evaluate correlations between assessment or feedback tools and remediation.

Multidisciplinary Team Approach in the Management of Tracheostomy Patients

Objective To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy. Study Design Case series with planned data collection. Setting Urban, academic, tertiary care medical center. Subjects and Methods Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost. Results Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center. Conclusions Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.

Difficult Airway Response Team: A Novel Quality Improvement Program for Managing Hospital-Wide Airway Emergencies

BACKGROUND:Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS:We developed a quality improvement program—the Difficult Airway Response Team (DART)—to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS:Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management–related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART’s teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS:DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.