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Extubation is a high-risk endeavor in some COVID-19 patients. Host Pamela M. Peeke, MD, MPH, FACP, FACSM, is joined by Joshua H. Atkins, MD, PhD; Christopher Rassekh, MD; and Ara Chalian, MD, to discuss recognizing risks surrounding extubation in ventilated COVID-19 patients, provide framework for rapid assessment and iterative change in complex care settings, and identify essential elements of integration of data and teams for implementation of new care pathways. This episode’s guests are from the University of Pennsylvania Medical Center in Philadelphia, Pennsylvania, USA. Dr. Atkins is an anesthesiologist and Drs. Rassekh and Chalian are ENT surgeons. This podcast is supported by an unrestricted education grant from Medtronic.
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This podcast is supported by an unrestricted education grant by Medtronic.
Dr Pam Peeke: Hello and welcome to the Society of Critical Care Medicine's iCritical Care Podcast. I'm your host, Dr. Pam Peeke. Today, we're going to be talking about the successful integration of new interventions across multiple care settings that reduce COVID-19 risk to the provider and patient.
I'm joined by three physicians from the University of Pennsylvania Medical Center, Dr. Joshua Atkins, an anesthesiologist and Airway Safety Committee co-chair; Dr. Christopher Rassekh, an ENT surgeon and otolaryngologist, Airway Safety Committee co-chair; and Dr. Ara Chalian, an ENT surgeon, otolaryngologist, Systems Safety Officer. Welcome to the podcast, gentlemen.
Dr Ara Chalian: Thank you. Great to be here.
Dr Pam Peeke: Awesome. Okay. Now, before we start, do any of you have any disclosures to report?
Dr Joshua Atkins: This is Josh Atkins. I'm a Medtronic consultant, and I have research funding unrelated to the contents of this presentation by the Becton Dickinson Corporation.
Dr Christopher Rassekh: And I'm Chris Rassekh and I am also a consultant for Medtronic, and I'm a co-investigator on a grant with engineers from Drexel University, which led to a patent pending that's been assigned to the University of Pennsylvania.
Dr Pam Peeke: Excellent. Thank you so very much. All right, let's get to the podcast. One of the references that I have in front of me here about your wonderful work really speaks to a quality and safety framework that you developed. And this was called the iReady Conceptual Framework for integration, root cause analysis, evidence review, adaptation, dissemination and implementation, and this is to help healthcare organizations respond to quality and safety challenges during crises, obviously we're in the middle of a viral pandemic and that qualifies. So Dr. Atkins, could you speak to this because I know you were on this team that put this together.
Dr Joshua Atkins: Hi. It's wonderful to be here, Pam, with you and my distinguished colleagues from Penn and the great members of the Society of Critical Care Medicine. This framework really just helps to cogently describe the coordination of response to airway issue related to COVID-19 patients that we experienced at Penn Medicine.
Fundamentally, we relatively early in our experience with mechanically ventilated patients detected that patients who were intubated for an extended period of time were encountering two problems obstructed endotracheal tubes requiring high risk tube exchange and also patients with COVID-19 who otherwise seem ready to be extubated requiring high-risk reintubations that were often challenging at a relatively high rate.
And so what we'd really like to focus on and I think discuss here is how we responded to those two challenges from a systems-based perspective and what went into that. And the highlights for this iReady framework really are what we took advantage of in our existing operation to put them together to tackle this problem.
How we used our critical care collaborative, which brings critical care experts from every ICU in our six-hospital system together into an integrated framework, how we horizontally integrated our experts from every division that might be involved in an extubation or reintubation from nursing and critical care to otolaryngology and anesthesia and how we used existing frameworks like the daily safety huddles, the ability to rapidly identify events in electronic reporting systems and bring those through the leadership quickly to groups like the Airway Safety Commitee to bring those experts to bear, and then use our overarching COVID-19 structural framework to disseminate best practices and to get input from all the clinicians on their interpretation of the events, the evidence, and what we could do to ameliorate the problem.
Dr Pam Peeke: such a comprehensive framework. And really, congratulations to you and the team, all three of you involved in this as well because this is truly integration in a dynamic context of this viral pandemic, looking at the quality and safety teams, both vertically and horizontally and really helping organizations streamline communications, and this involves clinical concerns, collaboration, solutions. Also, there was one other highlight from this, which I really wanted to stress too, and that is technology. Tell me about ICU telemedicine and how that figured in.
Dr Joshua Atkins: I think the two aspects that really came together incredibly well here are the tele-ICU, which to some extent developed from its infancy at the University of Pennsylvania Health System, and was really able to help in integrating and coordinating some of these processes across diverse units and really helping to answer questions on the fly for providers at the bedside, and also able to do some auditing and surveillance to help with compliance. But that also integrated with our use of the EHR and an ICU dashboard, which was available to every intensivist, which described some of the parameters of our risk reduction initiatives around these airways in real time for each patient on an integrated dashboard to catalyze discussions on rounds. And then Ara can elaborate from the overall Systems Safety perspective.
Josh the tele.
Dr Ara Chalian: helped of our organization grow as we tried to staff and create 24-hour coverage in areas that hadn't had it. And the pandemic created a need to reach even farther out of our units and in addition to minimize the presence in the room. So the concept of the tele-ICU has allowed us to explore doing intubations and mobile ICU care in domains that we would have never considered before with less people in the room.
The other thing the tele-ICU team has allowed us to do is not only create data theoretically, even document things videographically, but having an observer who's highly skilled, who's a clinician participant, who's not in the heat of the battle. They're aloof from some of the other physical stressors of being there and they can give us an incredible perspective. So the tele-ICU has really played a key role in allowing us to achieve some of our acuity ramp up and mobility in terms of minimizing the transport of patients.
Dr Joshua Atkins: I think that's a really great point, Ara, because one of the things that we really hadn't tested before COVID-19 was taking a mobile cart and essentially taking the ICU to the patient. And so as a result during COVID-19, we were rapidly able to deliver coordinated ICU care to the bedside in locations that otherwise weren't your traditional intensive care units.
Dr Pam Peeke: This is fantastic. I mean I really wanted you to articulate this for everyone to understand that we're really utilizing resources to be able to meet this challenge in a very creative way. I'd love the thought of taking that cart and moving it around and being able to adapt and adjust to all of these challenges. Well done.
So this iReady was published in the New England Journal of Medicine Catalyst. And this is basically framework to prepare for and respond to quality and patient safety challenges during this time, let alone what's going to happen in the future, because again so much of this is dynamically changing. Have you noticed adaptation of the iReady by other organizations?
Dr Joshua Atkins: I think the iReady was sort of an existing framework that we applied in this sort of unique application in the COVID-19 pandemic. So I do believe it's applied in other organizations, but I'm not specifically aware of which ones are using it.
Dr Pam Peeke: Well, I'll put money on it that the answer is yes. because...
Dr Ara Chalian: I would agree.
Dr Pam Peeke: Yeah. Well, of course, you would. You're slightly biased. But the bottom line is that it is just so easy to read, it is a fabulous reference and resource, and I can't imagine that other organizations haven't immediately grabbed it and adapted it to their own unique circumstances.
Let's pivot a moment now to an adaptation of this as it relates to extubation of ventilated COVID-19 patients. We have already mentioned the issue of the need for ventilation. now what do you do with extubation? What is the thought process, the decision-making, as it relates to everything from safety for staff, as well as obviously the well-being of the patient? So who'd like to walk through that?
Dr Joshua Atkins: I think the key element here was that we've recognized at Penn Medicine through the work of many including the Airway Safety Committee, that extubation is actually a fairly high risk endeavor in a lot of critically ill patients. And so focus has traditionally been on intubation and we at Penn Medicine across the entire system several years ago implemented a high-risk extubation process. And in our system, every single mechanically ventilated patient needs to be screened against a set of criteria for the possibility of being high risk in terms of difficulty putting the breathing tube back in should that be necessary.
After they're screened, if they're high risk, they're labeled with a sticker on their pilot balloon. They get an entry into our EHR, which alerts clinicians when they place an extubation order, that special considerations may be needed to undertaken. And then the teams should also enter a formal extubation plan that the intensivist can consult at the time of extubation.
And this really, the work of the critical care collaborative, of Dr. Rassekh and the Airway Safety Committee, of Dr. Chalian from the System Safety viewpoint, has really been an integral, coordinated approach to highlighting and educating people on the risk of extubation and formalizing a process to reduce that. We were able to leverage that immediately during COVID-19 because the moment this problem peaked in our systems, we automatically labeled every COVID-19 intubated patient as a high risk extubation and we're able to set off a structured protocol fairly quickly.
Dr Ara Chalian: To bounce off of what Josh articulated, graphics on guiding the respiratory therapist, ICU team, the residents, and even the family on what will be the expectations as the person journeys towards excavation are outstanding, and even the caveat like this needs to be updated frequently.
But I can tell you one other key feature of this team that I was able to appreciate and observe is when an untoward event happens, you know, somebody decompensates after the extubation, this team huddled, whether it was a Saturday morning or another point in the day. And they may not have had the chance to do an RCA, but they looked at the evidence and then they use the rest of the iReady to help adapt and disseminate and integrate the next set of steps, not only to care for that individual patient, but potentially to make interventions that would affect the care of the next patient approaching that transition from intubated to extubation, so that no patient under the care of this now quite large group spanning all parts of our organization would miss out on an opportunity. No clinician would miss out on an opportunity to benefit from that other patient and team's experience. It could only be an hour or two later, the interventions.
Using this structure would allow us to adapt our care patterns. And we don't normally get that, right, Pam? You know this, and I know this as we don't normally get that kind of live-time feedback that lets us change the care that we're delivering to the next patient.
Dr Pam Peeke: Oh, there's no question about that. And if you look at the COVID patients, there's absolutely no question that there were a lot of surprises. The first one I would imagine that related to the COVID was this elevated rate of airway morbidity. And that included obstructed ET tubes, airway edema after extubation. Take us through the process. How long did it take before you were able to reduce all these events to near zero?
Dr Christopher Rassekh: If I could just add a little bit to what Dr. Atkins said, and hopefully it'll somewhat answer that question as well. The high risk extubation protocol, as Dr. Atkins and Dr. Chalian alluded to, is a very robust system that really took advantage of the structure that we had built in with the critical care consortium and the Airway Safety Committee.
And I won't ever forget Saturday afternoon when Dr. Atkins texted me and said, "Emergency phone call." And I said, "What an emergency phone call?" And so then I looked and saw that there was this emergency phone call that was about to happen. And the emergency phone call was about a patient decompensating after extubation and the realization of this airway edema problem. And that had really at the time not been reported. And before that happened, I certainly didn't recognize that all extubations for COVID-19 patients were going to be high risk.
And so again, utilizing the existing framework that we had with the critical care teams and the Airway Safety Committee, it was my role as an otolaryngologist to help evaluate how we were going to approach this problem, because extubating a patient who then can not be reintubated of course is extremely life-threatening and this then led to a systems critical care consortium virtual meeting, where various options were discussed.
And where an otolaryngologist comes into play here, of course, is in interacting with the critical care team to determine how are we going to assess this. And so there was discussions about doing video laryngoscopy prior to extubation. There were discussions about doing flexible laryngoscopy. And ultimately after considerable multidisciplinary discussions, it was felt that this was not likely going to impact this.
And one of the big challenges I had as the co-chair of the Airway Safety Committee was taking what was happening at the critical care level and then communicating it to my own department faculty, because they didn't quite have the same framework. Of course, Dr. Chalian did, but a number of our faculty didn't understand the background and we just also had a podcast that discussed our approach to tracheostomy.
And much like that process, it really evolved as a multidisciplinary discussion where communication became so important. And so some of the recommendations that you'll see in the iReady are based somewhat on this. And so the use of steroids and leak testing prior to extubation and actually the decision that we would then go on to tracheostomy in patients who failed. And it really overlapped quite a bit with our discussions in the tracheostomy task force. So as a result, we were able to manage that problem. And similarly, I think Dr. Atkins can comment on how they manage the secretion problems. There was a change in the heat and moisture exchange devices. And so, we had just frequent meetings with our multidisciplinary team, respiratory therapy, nursing and so on.
Dr Pam Peeke: Dr. Atkins, do you want to add to that?
Dr Joshua Atkins: I think what all I'll say is that it was really a bi-directional communication, which made it really impressive. If was the safety leads from the health system, it was the critical care consortium directors and really providing back one of the natural answers to many airway problems with edema is, well, give steroids.
And so a simple recommendation might come out to give steroids and we immediately had the discussion that there was concern about delirium with steroids in an already high-risk delirium population. And as a result, the otolaryngology teams who have a lot of experience, like Dr. Rassekh and Dr. Chalian, with steroids, were able to discuss in real time the evidence on that with the delirium and we actually modified the dose of steroids and the timing of the steroids to try to optimize the benefit for the airway but minimizing the risk of delirium.
And you can see if this process wasn't being done in real-time with dynamic bi-directional communication. Some guidelines could have come out that would have ruffled some feathers and probably not being implemented in some settings, but instead we came out with something that was high-impact, but also universally supported.
Dr Pam Peeke: Wow. So lack of coordination or structure in process and safety improvement efforts can lead to less effective implementation of all of these new pathways. This is really something that you're driving home in a big way, everyone working together because certainly extubation was never anticipated to be a high risk endeavor. And then, surprise, it was and COVID 19 patients now have a very potentially significant safety risk. And this is why all of this transpired. Dr. Atkins, is there a role for simulation
Dr Joshua Atkins: I think all of us, Rassekh, Chalian and I have all been very involved in simulation in our health system. And Penn Medicine has really been a leader in using what we call Insight U simulation, real simulation in the clinical environment with the actual clinicians, doing the actual procedure in real time. For example, we used that to assess the readiness of some of our units to handle COVID patients before they actually opened. And we have used that to simulate emergencies in airways in COVID patients to make sure that the teams realized that how emergency rescue of a patient who had just been extubated differed in regard to preparation, PPE, what kind of expectations there would be for resuscitation. And those simulations helped both iron out some kinks, recognize some equipment deficiencies, and also build confidence in the responders. And by recording those simulations, you can potentially reach a larger audience because it is a very resource intensive endeavor.
Dr Pam Peeke: Excellent. And I'm going to throw this little challenge out to you that is we’re going to have more variants of the COVID-19. We already know that very shortly we will have fairly intense penetration of what we now call the UK variant, which is much more contagious than the current variant which is dominant in the United States now. But within a period of the next three months, the UK variant will be much more contagious. Tell me your thought process on how you're going to deal with this challenge.
Dr Ara Chalian: Well, Pam, as a systems-based kind of big picture quality and safety perspective. I would say the teams need to visit what they do. They need to build out their structure of dealing with day-to-day operations, like it should be very codified both visually and stepwise and potentially in their electronic health record how they do certain things, whether it's intubation extubation or reporting.
And so if we go back to kind of safety and quality basics, if you don't measure it, you can't react to it. And if you don't define what you want to measure, you can't react to it. So I think the next question is what do we keep measuring? And do we need to measure things? Other things like, is there a way to measure aerosolization in these moments? Do we need to prep our teams differently to do an emergency airway rescue?
In one of these extubations that in spite of the best practice, the person's physiology or anatomy tipped them over the edge. So I think, one, defining what we do measure and being ready to respond to it. Because if you look at the graphs in the iReady paper, the team's responses to airway obstruction while intubated or reintubation, numbers was very rapid. Within 10 to 12 days of recognizing the problem, solutions were on the table and occurrences dropped down. And that kind of rapid cycle change is what we're going to have to be ready for.
Dr Pam Peeke: I think that this is incredibly important for all of your peers to hear, and that is we're living in an uncertain world. And you've got to be able to have a framework for decision-making and for strategic changes to take place that rapidly. You mentioned, what was it? Ten days? That's the kind of rapidity that we're really striving to be able to achieve because we don't know what's going to be coming next. And so this viral pandemic has really presented us with countless opportunities to refine the system and keep it alive, dynamic and responsive to adapt and to adjust to all of this.
Now I'm going to ask each one of you to sit back for a moment and think to yourself from this discussion that we've just had about strategic decision-making, about having that framework, about being able to respond in a collaborative way across a healthcare system, et cetera, what nugget of wisdom could you share with your peers that you really want to make certain to drive home from this entire discussion? What's really important when you think about the practical applications we're speaking to? What would really help one of your peers out there? I'll start with you, Dr. Rassekh.
Dr Christopher Rassekh: Well, first of all, I want to thank you, Dr. Peeke, and thank the Society of Critical Care Medicine and my colleagues, Dr. Atkins and Dr. Chalian, for allowing me to participate in this and work on such a challenging, but interesting problem.
And you mentioned the new variant and that we're seeing a tremendous surge of cases not only in the United States, but worldwide, and this is creating a lot of anxiety. We have become better at managing patients with COVID-19, including the management of critical care patients.
So I just want to make two points. One is that for hospitals that don't have as robust an infrastructure as we do, work on building it. We weren't always like this. We started this about eight years ago with a meeting, basically just a working group. And our working group has evolved to develop all of these protocols and has become a formal Airway Safety Committee that reports to our critical care consortium.
So communication within the institution is critical and it takes time and effort and you build those building blocks one day at a time. And so having that in existence will help prepare you for not only this pandemic, but for the next crisis that hits your hospital. And we're certainly available to help guide people on how to build that structure.
And also given that we're going to have a lot more survivors, I'm just going to direct you to an article that a number of us wrote that was led by Michael Brenner, that was just published about COVID-19 survivorship and specifically for the otolaryngologists and how we restore confidence in people, given the complications that arise in critically ill patients. And part of my communication with our critical care consultants is to recognize that we're not only thinking about the short-term, but the long-term and to work with them to advance survivorship, but also to think about what happens in the survivorship phase,
Dr Pam Peeke: Excellent. Excellent. Wonderful summary. Dr. Chalian, your thoughts?
Dr Ara Chalian: Well, Dr. Peeke, thank you for joining us all together. And then also to those of you in the Critical Care Society, thank you for all the work you do and your teams. And I don't know if you get enough pats on your back, but I think these teams deserve more than that.
My nugget is that if you think about this as overarching horizontally and vertical integration, a lot of it's there, but it can be overwhelming. Start locally. Build your team. Be inclusive. Set up time to have a rapid fire huddle with a structure and outline that you follow and then set up time every couple of days to talk about data, impressions, gut feelings and opportunities. And that will take your team to the next level, both in confidence, as well as quality and outcomes.
And if you carry that forward and you've got to tell your bosses you're doing this, that's where the up and down comes in. It'll touch every aspect of your practice and your unit beyond COVID times. These are tools that will make us better for the long haul.
Dr Pam Peeke: Communicate, communicate, communicate. You can't say it enough, really. And to honor every single person's role on that team. This is all team-based and, boy, if there's a central theme, that's exactly what it is. And communicating one team to another, across a healthcare system is just absolutely essential. Dr. Atkins, your thoughts?
Dr Joshua Atkins: Thanks, Pam. It's been a pleasure to be here and share this information, this wonderful conversation with the society and my colleagues. I think I can't agree more with the group about communication and, you know, really along those lines is emphasized here. This idea of think as broad as you can about who might have input and impact to your process optimization.
You know, it's talking to care folks. Sometimes it's rare to have an otolaryngologist or someone that's so far out from your usual purview on say the airway that may have some important information and can contribute broadly. And so along the lines of what Dr. Chalian said, the data is so important and figuring out ways to use the data you already have and getting it frequently and reliably into the right hands.
And for example, one thing that we've done is we've started to collect our safety nets, our safety reports and we've pull out the ones that are specifically related to airway. And we disseminate those specifically to wider experts involved in the airway so we can discuss them together. And that happens weekly.
So by getting these communications as part of our habits, our weekly habits of talking across disciplines, but about specific issues, we think that can be more effective.
Dr Pam Peeke: Excellent wisdom from every single one of you. Doctor, thank you so much for being on this podcast. This concludes another edition of the iCritical Care podcast. For the iCritical Care podcast, I’m Dr. Pam Peeke.
This podcast is supported by an unrestricted education grant by Medtronic.