ntensive care medicine trainees’ experience of percutaneous dilatational tracheostomy insertion: a...
TRANSCRIPT
DR KAREN ORR, ST7 ICM/ANAESTHETICS, UHD
DR CONN RUSSELL, CONSULTANT INTENSIVE CARE/ANAESTHETICS, UHD
DR CHARLES PHILPOTT, CONSULTANT ANAESTHETICS, UHD
Intensive Care Medicine Trainees’
experience of Percutaneous Dilatational
Tracheostomy Insertion:
A UK wide survey
• Background
• Outline of survey design
• Results
•All trainees, ST7+ trainees, NI trainees
• Discussion
BACKGROUND
NCEPOD “On the right Trach?” (2014)
• Estimated 8000 PDT insertions annually in the UK
http://www.ncepod.org.uk/2014report1/downloads/On%20the%20Right%20Trach_FullReport.pdf
• Lethal cases btwn 1985 and 2003
• 71 cases: 0.17% of all pts. or 1 in 600 pts.
• 31% during procedure
• Haemorrhage (38%), airway complications (29.6%),
tracheal perforation (15.5%), PTX (5.6%),
bronchospasm (4.4%), arrhythmia/cardiac arrest
(4.4%) and sepsis (1.5%)
• Bronchoscopic guidance only in 46.5%
Competency Level Descriptors
Domain 5: Practical procedures
ACCS CAT CMT ST Stage 2 Stage 3
5.6 Performs percutaneous tracheostomy
0 0 0 1 3 4
SURVEY DESIGN
Survey Content
• Demographics
• Experience of PDT insertion
•Direct/ indirect supervision
• Self perceived level of competency
DEMOGRAPHICS
• Approximately 400 UK ICM trainees
• 116 complete responses (29%)
• 6 Northern Ireland responses (75%)
• 39 trainees at ST7 level and above
• All training grades, deaneries and base
specialities represented
Number of PDTs performed in career so far - Direct supervision
All trainees, completed responses only
43%
4%9%4%
9%
9%
4%3% 7%
0%8% Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Number of PDTs performed in career so far- Indirect Supervision
All trainees, completed responses only
71%
9%
4% 5%
2% 2%2%
1% 1%1% 2%
Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
PERCEIVED COMPETENCY
Do you feel competent to perform a PDT with direct supervision?
All trainees, completed responses only
86%
14%
Yes
No
Do you feel competent to perform a PDT with indirect supervision?
All trainees, completed responses only
44%
56% Yes
No
TRAINEES ST7 AND ABOVE
Number of PDTs performed in career so far- Direct supervision
59%
0%2%
5%
3%
8%
3%0%
10%
0% 10% Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Trainees ST7+, completed responses only
Number of PDTs performed in career so far- Indirect Supervision
51%
15%
5%
8%
2%0% 5%
3%3% 3%
5% Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Trainees ST7+, completed responses only
Do you feel competent to perform a PDT with direct supervision?
Trainees ST7+, completed responses only
95%
5%
Yes
No
Do you feel competent to perform a PDT with indirect supervision?
Trainees ST7+, completed responses only
69%
31%
Yes
No
NORTHERN IRELAND TRAINEES
Number of PDTs performed in career so far- Direct supervision
NI trainees, completed responses only
33%
0%33%
17%
0%17%
0% 0% 0% 0% 0%
Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Number of PDTs performed in career so far- Indirect Supervision
NI trainees, completed responses only
83%
17%
0%0%0%0%0%0%0%0%0%Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Do you feel competent to perform a PDT with direct supervision?
NI trainees, completed responses only
50%50%
Yes
No
Do you feel competent to perform a PDT with indirect supervision?
NI trainees, completed responses only
17%
83%
Yes
No
COMPARISONALL TRAINEES V ST7+ V NI
All TraineesST7+
TraineesNI Trainees
Career, >2 PDT- Direct
61/11652.6%
16/3941.0%
4/666.7%
Career, >2 PDT- Indirect
23/11619.8%
13/3933.3%
1/616.7%
% Self perceived
competency-Direct
100/11686.2%
37/3994.9%
3/650%
% Self perceived
competency-Indirect
51/11644.0%
27/3969.2%
1/616.7%
COMMENTS
Additional Trainee Comments
• Generally inadequate exposure and training opportunities
lacking- many responses from trainees
• Wide variety in training opportunities
• Seldinger technique is a generic skill and PDT should only
require a small number of supervised observations
• Number of PDTs inserted is falling and with it, exposure for
training
• Some consultants struggling to maintain their own skills with
falling numbers , before training junior staff
• Should a small number of consultants in each unit
maintain PDT insertion skills- a specialist rather than
generic skill?
• Skills in managing complications e.g. bleeding are lacking
• Variation between units on focus on training ICM trainees
specifically (above anaesthetic trainees or speciality
doctors for example)
• Uncommon to perform without a consultant present
undertaking bronchoscopy
CONCLUSION
• 86% of all, 95% of ST7+ and 50% of NI trainees feel
competent to perform PDT insertion with direct
supervision
• 44%, 69% and 17% respectively with indirect supervision
• Some inaccuracies with reported numbers, particularly
ST7+ trainees
• Perceived inadequacy of training opportunities (falling
numbers, consultant skill maintenance, training of non
ICM trainee doctors)
• Should it remain a core skill for all Intensivists?
Thanks
• Dr Conn Russell (Consultant Intensive Care,
UHD)
• Dr Charles Philpott (Consultant Anaesthetist,
UHD)