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Structured Training for Anaesthesia Novices (STAN)
A Programme for Doctors New to Anaesthesia based on Mastery Learning Principles
Training Manual
A collaborative project from the Royal Alexandra Hospital (RAH), Paisley and the Scottish Centre for Simulation and Clinical Human Factors
For more information or any queries: [email protected]
David Ure
Al May
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Contents
2 Quick guide 3 Introduction 5 Mastery learning method 6 Skillsets introduction 7 Skillset 1-Preoxygenation 9 Skillset 2-Facemask airway (2-handed) 11 Skillset 3-Facemask ventilation (1-handed) 13 Skillset 4-Laryngeal mask airway 15 Skillset 5-Endotracheal intubation 17 Appendix 1: Cusum chart (preoxygenation)
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Quick Guide for Trainers What is STAN? A way of training where practical activity is focussed, limited and standardised. Why are we using it? Some of these principles come from a technique (mastery learning) that has a large evidence base showing it to be more effective than traditional training. What do I need to do?
1. Let the new start trainees do the “one skill” of the day on the patients on your list.
2. Give them feedback based on the “measures that define success” for the skill.
3. Feedback needs to happen every time they perform the skill with you.
What are the skills? • Preoxygenation • Facemask Airway (2-handed) • Facemask Ventilation (1-handed) • LMA insertion • Intubation What should I avoid doing? Don’t let the focus of your interaction be about anything other than the “one skill”. Try to avoid saying things like “this isn’t the way I do it…”. That’s it? Yes, that’s it
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Introduction Beginning in August 2014, the Department of Anaesthesia at the RAH piloted a new training programme for some areas of anaesthetic practice. Our aim is to produce capable and confident junior anaesthetists more reliably and in a shorter time than with our previous training model. Although many of the ways in which we train people will remain the same, there will be fundamental changes to the way we train some key skills. Traditional learning of anaesthesia technical skills has been largely based on Halstedian apprenticeship (see one, do one, teach one). There is a large body of work that has shown improved skill acquisition and retention using a method called mastery learning. This involves (amongst other things) deliberate practice of one skill at a time (e.g. face mask ventilation alone) with formative feedback and reflection every time the skill is employed, rather than general acquisition of an entire complex process from day one (e.g. giving an anaesthetic from start to end). In studies to date, employing mastery learning, the skill is practiced using simulation with gradual increase in difficulty, leading to achieving the minimum pass score for the skill in a shorter time span, with long-term skill retention and consistent performance. There is also a reduction in performance variability between doctors when skills are taught in this way, and indeed studies showing improved patient outcomes. Progress in skill acquisition will be monitored using cumulative summation (CUSUM) charts.* A key part of using the CUSUM charts is the annotation of reflections on recurrent successes and significant failures. Our pilot project is using some of the principles of Mastery Learning but in a real clinical environment, and aims to achieve a high level of performance in skills to the point where they become automated or semi-automated. This allows greater ability to continue acquiring and processing other information while performing the task. *RCOA bulletin 54: CUSUM charts: ctrl + left click on this link to go to an RCoA bulletin containing a summary of CUSUM charts.
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The Structured Training Approach ‘Feedback every time’
Airway Module: There will be a stepwise approach to skill acquisition for the following procedures:
1. Preoxygenation 2. Facemask airway (two-handed method) 3. Facemask ventilation (single-handed method) 4. Laryngeal mask insertion 5. Intubation
The general format for learning the skill will be as follows: • Each trainee is assigned a base theatre list on the rota as usual • On the morning assigned to learning the skill in question, trainees will have a short
presentation and practice simulation before attending their base list • They should get experience with the skill of the day on every suitable patient on the base
list and any other patients on any other list in the theatres • During the assigned training period, the sole focus of learning should be the designated
skill of the day • The aim is to do a high number of the skill of the day in a short space of time
• If it looks like the skill will be difficult to perform on a given patient, the trainer should
perform it instead as the intention is that the skill is learned with easy examples, progressing to greater difficulty once the basic skill is mastered
• Each performance of the skill will be subject to formative feedback, reflection and
assessment. Was the objective achieved? If not, why not? If it was, could the technique be improved? A CUSUM chart is used to track progress. This is integral to the whole process: feedback every time.
A major change for trainers is the idea that the trainee assigned to their list is not ‘their trainee’ for the day. Ideally, trainers should be alert for opportunities for the trainee to practice the designated skill elsewhere in the theatre suite. Also, consultants who do not have a trainee with them, or have a senior trainee, should actively seek out novices to allow them to get further experience. If it is “preoxygenation day” for the new start trainees, all patients in the theatre complex should be preoxygenated by one of the new start trainees.
A second major change is the focus on learning, assessment and feedback of only one skill at a time, rather than on the complex process of anaesthesia.
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Skills
It is important that the techniques are taught consistently. A lot of confusion is generated among novice anaesthetists because senior anaesthetists all tend to do things in a slightly different way. The aim with structured training is that all trainees learn exactly the same thing from every trainer they encounter. This will inevitably involve changes to routine practice by trainers. Once trainees have this basic, standardised technique of performing a procedure, they can begin to understand how it fits in to expert performance and how and why the technique might be modified. Time spent laying secure foundations should pay off rapidly.
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Skill 1: Preoxygenation Essential theory Preoxygenation involves giving 100% oxygen through a tight-fitting face mask for a period of time before induction of anaesthesia. The object of preoxygenation is to maximize the duration of apnoea before desaturation occurs. This gives the anaesthetist time to manage problems before harm occurs if difficulty is encountered. The physiological basis of preoxygenation is replacing the air within the functional residual capacity (FRC) of the patient’s lungs with oxygen. It can also be seen as denitrogenation of the FRC. The aim of preoxygenation is to achieve an end-tidal oxygen concentration of greater than 80%. In a healthy, young adult this will allow several minutes of apnoea before desaturation starts (fig 1). Duration of apnoea before desaturation can be decreased for a variety of reasons including obesity, pregnancy, lung disease, sepsis and abdominal distension. It is less effective in children because of their relatively smaller FRC and higher metabolic rate. Figure 1: Time to haemoglobin desaturation after preoxygenation
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Preoxygenation (expected duration: 1 day) • Trainees will have a short presentation on preoxygenation on the morning of the training
day. This includes simulation in theatre covering monitoring of patient, oxygen delivery with machine, and technical airway maintenance with facemask.
• Preoxygenation can be achieved with either of two methods.1 3 minute tidal volume breathing (TVB 3): good facemask seal, 100% O2, 3 mins tidal breathing or 8 deep breaths in one minute (8 DB 1): good facemask seal, 100% O2, 8 vital capacity breaths over one minute
Can J Anaesth 2009; 56: 449-66 • Trainees will preoxygenate patients on their base list and other lists as available
• Formative feedback is given after each event. A success is when all measures have been completed satisfactorily. This is marked on a CUSUM chart (appendix 1). Once the trainee has achieved 6 consecutive successes, they are deemed competent in preoxygenation.
The following measures will define successful preoxygenation: o Monitors on (pulse oximeter, capnograph, ECG, NIBP) and iv access o Face mask held on appropriately (good seal without distressing patient) o Reservoir bag moving satisfactorily with respiration and good capnograph waveform o Either TVB 3 or 8 DB 1 methods can be used. EtO2 greater than or equal to 80% to
completes the procedure.
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Skill 2: Face mask airway (2-handed method) Essential theory The most basic way to maintain an airway and allow either spontaneous or assisted ventilation is by using both hands to hold a face mask on the patient’s face to maintain an airtight seal. The airway is kept open to allow unobstructed respiration if the patient is breathing spontaneously. In an apnoeic patient, an assistant can squeeze the reservoir bag to achieve positive pressure ventilation. Vigilance is necessary to detect airway obstruction. Signs of airway obstruction:
• See-saw abdominal movement • Suprasternal indrawing • Noisy breathing • Absence of facemask condensation forming on expiration and disappearing on
inspiration • Laryngeal spasm can occur if the patient is too lightly anaesthetised. This can cause
stridor (a high-pitched inspiratory sound) and partial or complete airway obstruction.
An oropharyngeal makes maintaining a clear airway easier and should be used at all times during the training period. The correct size of airway should extend from the patient’s lips to the angle of the mandible.
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2-hand mask airway (expected duration: 1 day) • Trainees will have a short presentation on 2-hand mask airway on the morning of the
training day and practice the technique on the airway simulator. • Trainees will employ 2-hand mask airway in patients on their base list and elsewhere as
opportunities arise.
Optimal position: Neck slightly flexed. Head slightly extended on neck. The external auditory meatus should be at the same level as the suprasternal notch. Facemask technique Pull the jaw up into the mask, rather than pushing the mask down into the face. A: Helpful in patients with a big jaw. Only the most powerful hand muscles are used. Use the index fingers to thrust the mandible up and the thumbs to form a seal with the mask. B: Often helps in edentulous patients. The little finger is behind the angle of the mandible, the ring and middle fingers support the body of the mandible and the thumb and index finger seal the mask on to the face. The fingers can bunch the cheeks to ensure a face mask seal.
A B
• Formative feedback is given after each event. A success is when all measures have
been completed satisfactorily and the technique is sound. This is marked on a CUSUM chart. Once the trainee has achieved 6 consecutive successes, they are deemed competent in basic face mask airway management (2-handed method).
The following measures will define success of facemask airway (2-handed): o Adequate depth of anaesthesia (see appendix 2) o OP airway inserted o Position optimal (see below) o Facemask technique (spontaneous or assisted ventilation by trainer):
Hold the jaw into the mask, A or B technique acceptable (below) o Reservoir bag moving appropriately, Satisfactory capnograph waveform o Recognise signs of inadequate/obstructed airway if present
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Skill 3: Face mask ventilation (1-handed method) Essential theory Using one hand to hold a face mask in place allows the anaesthetist to ventilate the patient by squeezing the reservoir bag with their free hand. It is more difficult than the 2-handed method and is not possible at all in some patients. Constant vigilance for signs of airway obstruction is necessary. Covering the function of the APL valve and where the gas flows should be included.
An oropharyngeal makes maintaining a clear airway easier and should be used at all times during the training period. The correct size of airway should extend from the patient’s lips to the angle of the mandible.
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1-hand mask ventilation (expected duration:1 day)
• Trainees will have a short presentation on 1-hand mask ventilation on the morning of the training day and practice the technique on the airway simulator.
• Trainees will employ 1-hand mask ventilation in patients on their base list and elsewhere as opportunities arise.
Optimal patient position: Neck slightly flexed. head slightly extended on neck. External auditory meatus at same level as suprasternal notch. Hand position (see below): EC shape. Lower 3 fingers spider around the jaw in an ‘E’ shape. Index finger and thumb form ‘C’ shape on the mask. The jaw is lifted into the mask. APL valve: close the valve fully (i.e. turn fully clockwise) then open it slightly. This pressurises the circuit to allow bag/mask ventilation.
Formative feedback is given after each event. A success is when all measures have been completed satisfactorily and the technique is sound. This is marked on a CUSUM chart. Once the trainee has achieved 6 consecutive successes, they are deemed competent in basic face mask airway management (1-handed method).
The following measures will define success of facemask venitlation (1-handed): o Adequate depth of anaesthesia (see appendix 2) o OP airway inserted o Position optimal (see below) o Facemask technique (assisted ventilation by trainee): o Reservoir bag moving appropriately, Satisfactory capnograph waveform o Recognise signs of inadequate/obstructed airway if present.
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Skill 4: Laryngeal mask insertion Essential theory The laryngeal mask airway (LMA) is the most commonly used airway management device. It provides a stable, hands-free airway, it is technically straightforward to use and it is a vital airway rescue device. The LMA is inserted blindly to into the pharynx adjacent to the laryngeal inlet. Paralysis with a muscle relaxant is not necessary to insert an LMA. It does not provide protection from aspiration of gastric contents. The size of laryngeal mask used depends on the patient’s weight and the size of their mouth and oropharynx. Weight guides are printed on the side of the LMA. In general, LMA size 4 is used for an adult female and LMA 5 for an adult male. The maximal volume of air to be injected into the cuff is printed on the device. Once a seal is achieved, the cuff should be deflated slowly until a leak appears and then slowly inflated back to the point at which the leak stops. This ensures that cuff pressure is minimized and potential for mucosal ischaemia reduced.
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Laryngeal mask insertion (expected duration: 1 day)
• Trainees will have a short presentation on LMA insertion on the morning of the training day and practice the technique on the airway simulator .
• Trainees will learn LMA insertion in patients on their base list and elsewhere as opportunities arise.
Formative feedback is given after each event. A success is when all measures have been completed satisfactorily and technique is sound. This is marked on a CUSUM chart. Once the trainee has achieved 6 consecutive successes, they are deemed competent in basic laryngeal mask airway insertion.
Youtube link: Laryngeal mask insertion:
The following measures will define success of LMA insertion: o Adequate depth of anaesthesia (see appendix 2) o Insertion technique optimal-jaw lifted anteriorly, sweep contour o Confirmatory signs of adequate airway: capnography, chest movement o Recognise signs of inadequate/obstructed airway if present
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Skill 5: Endotracheal intubation Essential theory Endotracheal intubation provides a secure airway and a cuffed endotracheal tube (ETT) protects the patient from aspiration of regurgitated gastric contents. It can be a difficult skill to master, although new technology (videolaryngoscopes) has made the skill much easier. Managing the airway and achieving satisfactory oxygenation and ventilation is always the priority, rather than successful intubation. Once intubation has been learned, trainees will progress to learn intubation with a bougie. Key points for trainees using a bougie include; only using for grade 2B and better, always keeping someone’s hold on the bougie, avoiding excessive insertion, and clear communication (“let me know when you have the end of the bougie” and “bougie out please”).
Laryngeal anatomy Knowledge of laryngeal anatomy is essential. The link below is a good starting point. Laryngeal anatomy 1
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Endotracheal intubation (expected duration 2 days) (It is recognised that opportunities for intubation are less common than for the other skills in the STAN programme. This makes it even more important that on “intubation days” nobody apart from a new start trainee intubates a straightforward patient) • Trainees will have a short presentation on intubation on the morning of the training day,
including Simulation to practice the technique on the airway simulator. • Trainees will learn intubation in patients on their base list and elsewhere as opportunities
arise. • The patients selected should be predicted to be (and actually) easy to intubate. • Trainees should have a maximum of two attempts with a Macintosh laryngoscope and
a bougie must not be used initially. Trainees must verbaise the view they have. • If the trainee cannot get better than grade 3 view, the trainer should take over and this
only becomes an unsuccessful trainee attempt if the trainer achieves better than grade 3 view.
• Once they have achieved 6 consecutive successes, they will repeat the process using a
bougie to intubate, employing the same 3 points above.
Formative feedback is given after each event. A success is when all measures have been completed satisfactorily and technique is sound. This is marked on a CUSUM chart. Once the trainee has achieved 6 + 6 consecutive successes, they are deemed to have achieved basic competency in intubation.
The following measures define success of intubation: o Optimal Position (see previous) o Clear communication as above (esp when progressing to bougie) o Successful intubation of the trachea confirmed with capnography o Auscultation to confirm ETT above carina o No lip / dental / oral trauma
Appendix 1: CUSUM (Preoxygenation) The chart shows 2 successes followed by a failure, then 4 consecutive successes, a further failure and 6 consecutive successes. The increments are chosen for an arbitrary success rate of 90% for the procedure. The failure increment is therefore 9 squares and success decrement 1 square. A downward or horizontal slope shows improvement.
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CUSUM: Preoxygenation
Number of procedures
Failure results in increment of nine squares. Reasons for failure are annotated (above right).
Success results in decrement of one square (or no change once zero line is reached)
Sixth consecutive pass signifies competency. The aim is not to reach the baseline, but to have a declining slope.
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Annotate reasons if unsuccessful e.g.: 1. Unable to obtain capnograph waveform 2. Failed to attach pulse oximeter
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Appendix 2: Assessment of depth of anaesthesia • There is a delay between the end of injection of propofol and the patient being deep enough to allow safe airway manipulation and instrumentation, as the drug takes a short time to reach peak effector site concentration. Assessment of depth of anaesthesia should consider a number of variables:
1. Loss of jaw muscle tone: jaw muscle tone reduces as anaesthesia deepens 2. Loss of general muscle tone: often noticeable as the patient’s arms relaxing from a flexed position 3. Pupil constriction: pupils symmetrically constrict with deep anaesthesia 4. Heart rate decrease: heart rate falls as anaesthesia deepens 5. Apnoea: patients often become apnoeic at induction
If in doubt, wait and/or give more propofol. Attempting to deepen anaesthesia with volatile agent in a patient who is in a light plane of anaesthesia can create airway problems (coughing, laryngeal spasm). (Note: Thiopentone alone does not suppress airway reflexes sufficiently to allow insertion of a LMA. 3-4 minutes deepening anaesthesia with sevoflurane is essential before LMA insertion if thiopentone is used as an induction agent.)
