While conducting almost 30 Train-the-Trainer seminars over the world, I discovered a dilemma. Bronchoscopists rarely practice crisis management, especially when the crisis is caused by a bronchoscopy-related adverse event. It’s a fact; generally-speaking, that bronchoscopists rarely, if ever, practice how to manage procedure-related complications in the bronchoscopy suite.
While it is true that flexible bronchoscopy is usually safe, complications can and do occasionally occur. These include but are not limited to respiratory insufficiency caused by over-sedation, biopsy-related bleeding, pneumothorax, respiratory insufficiency from hypoxemia, hypercapnia or underlying lung disease, medication-related seizures, cardiac dysrhythmias or cardiac arrest, and very rarely death.
Bronchoscopists are not alone when managing these complications. They are the leaders of a team of nurses, technicians, and other health-care providers called to the bedside in case of an emergency, and everyone agrees, I am sure, that medical emergencies are best handled by an experienced and well-trained team.
There are many reasons why bronchoscopists and their teams are not regularly practicing crisis management. Some are lack of administrative oversight, lack of institutional quality control and complication management mandates, time constraints, the rarity of procedure-related adverse events, the absence of objective measures with which to measure competency, and the unfair presumption of personal expertise and emergency preparedness.
We know practice does not make perfect…rather, perfect practice makes perfect. Our patients expect us to be prepared for emergencies, to respond to emergencies appropriately, and to be accountable for our actions. To avoid accusations of negligence or malpractice, bronchoscopists should have a strategy in place in case of a procedure-related complication. They should be able to respond to the complication appropriately and according to a reasonably acceptable standard of care, and they must assure the result of that response is in accordance with expected outcomes, standard of care, and published results by colleagues.
To put it simply, standard of care is a level of care delivered by similarly trained physicians providing care in a similar environment and in a similar situation. When it comes to procedure-related complications, standard of care relates not only to a physician’s behaviors, but also to the training, preparedness and behaviors of the bronchoscopy team. For these reasons, bronchoscopists must be well-trained, and able to ensure their team responds to complications appropriately, effectively, and in ways that maximize patient safety and well-being.
Being prepared for complications requires practice. Identifying organizational weaknesses, system errors, and documenting sentinel events leads to troubleshooting areas that may require additional focus or training. Such remedial actions reduce anxiety, enhance confidence, and provide a good example for students, ancillary staff, and trainees. It also improves quality of care, especially when checklists, clinical pathways and database quality of care database tools are used.
Incorporating a competency-based assessment such as the new and validated ICC-STAT (Intercostal catheter skills and task assessment tool-downloadable from www.bronchoscopy.org) provides an opportunity to guarantee, for example, that chest tube insertion (which could be necessary in case of procedure-related pneumothorax) is performed according to a reasonable and globally acceptable standard of care. By practicing chest tube insertion in a simulated environment, bronchoscopists and their teams assure that emergency equipment is available, the team knows where to find the equipment, appropriate drugs, instruments and capital equipment are used correctly, patient assessments are consistently performed, and monitoring is done accurately. Setting aside time to practice with the team and documenting that such practice occurs is an important step toward quality improvement and assuring an appropriate and effective response to procedure-related complications. As a friend of mine once taught, “There should be no surprises in the procedure suite.”
Our patients expect no less.