Identifying and assessing human factors surrounding the introduction of high frequency ventilation during neonatal transport with simulation.
TimeThursday, April 152:00pm - 3:00pm EDT
LocationEducation and Simulation
Specialized care of high risk, critically ill neonates often requires the adoption of new technology into clinical practice. Neonatal transport is an evolving branch of medicine, and significant research has been devoted to improving the process. High frequency ventilation (HFV) during neonatal transport allows for infants with the most severe cardio-pulmonary pathology to be transferred to higher levels of care for surgical, hemodynamic and pre-ECMO assessment. In our Neonatal Intensive Care Unit (NICU), HFV is primarily used in both first intention as well as rescue modes, however our transport team exclusively uses conventional mechanical ventilator. The introduction of a new high frequency transport ventilator (HFTv) created an opportunity to assess human factors-associated potential patient safety threats though the use of simulation.
A team of neonatologists with transport and simulation experience created 3 short simulation scenarios involving the high frequency transport ventilator, each lasting approximately 5 minutes. Objectives of the simulation were to identify and evaluate latent threats to patient safety and demonstrate proficiency with the ventilator setup and use. The three scenarios involved: 1) initial transfer of a clinically ill neonate from a high frequency oscillating ventilator to the high frequency transport ventilator, 2) making adjustments in the transport ventilator to optimize the neonate’s oxygenation, 3) making adjustments in the transport ventilator to optimize the neonate’s ventilation. The transport team members were instructed in how to initially setup the ventilator and its multi-piece endotracheal tube (ETT) interface, where to adjust the mean airway pressure (MAP), frequency and amplitude, and how to assess these changes on the neonatal mannequin prior to the simulations. During team debriefing of the simulation, participants were asked to comment on human factors related to potential safety issues with the ventilator. Participants in the simulations included transport nurses (n=6), transport respiratory therapists (n=13), neonatology fellows (n=5) and faculty members (n=3).
Eight important human factors issues came to light as a result of debriefing and discussion during the simulations. First, the display of the ventilator is small and not back lit making the ventilator parameters difficult to view from a distance or without direct light. Secondly, control of the amplitude and frequency occur directly at the display, however adjustments involving mean airway pressure occur at a separate interface located near the ETT. Third, adjusting the amplitude or frequency involves turning the controlling knob in an opposite direction compared with the MAP. Fourth, lag time can last for up to 30 seconds from adjustment of the controls until the change is registered on the display. Fifth, the control-response ratio is sensitive; small changes in the dial can potentially result in large changes in the delivered pressures. Sixth, due to the design of the ventilator, all control adjustments are interrelated. For example, changing any of the 3 values (amplitude, MAP or frequency) results in changes to the other two parameters. We found repeated increases in amplitude for the purpose of lowering the infant’s PC02 levels resulted in a gradual increase in the mean airway pressure, a very important relationship to monitor when transporting infants at high risk of cardiac compromise and/or volutrama from overdistention. Therefore, for every change made in one control, the two other parameters had to be monitored and adjusted to counteract the unforeseen changes. This requires continuous communication between team members to relay ventilator values to all transport members, especially when the ventilator screen is small and the control for the MAP situated in a different location than the controls for amplitude and frequency. Seventh, repeated simulations noted the potential for increased tension and potential obstruction of the ETT at the connection site with the HFTv due to the large ETT interface required. This tension resulted in numerous transport team concerns regarding unintentional ETT disconnections or obstructions, and as a result an ETT extender was added to the setup to reduce the tension at the ETT transport ventilator connection point. Eighth, unique differences in setup, monitoring, and titration when using inhaled nitric oxide (iNO) through the HFTv were discovered. Through multi-disciplinary collaboration, specific teach-back sessions were created with the inclusion of additional iNO specific reference cards to ensure that all members were proficient with the utilization of iNO through the HFTv.
The use of simulation to prepare a high acuity neonatal transport team for the introduction of a new HFTv resulted in the identification of multiple human factor related threats to patient safety. Multiple simulations with transport team members uncovered eight human factors associated patient safety threats. None of these issues were insurmountable and multi-disciplinary collaboration were key to identifying and addressing these issues. The identification of these threats allowed for the introduction of corrective measures and further training sessions to reach a high level of proficiency and safety prior to the ventilator’s use in an actual transport. Additionally, the simulations highlighted the importance of multi-disciplinary collaboration between nursing, respiratory therapy and neonatologists. Without the shared expertise and knowledge from each field, the implementation of HFV in our neonatal transports would not have been successful.