BackTable / ENT / Podcast / Episode #96
Airway Foreign Bodies in Children: Risk Reduction
with Dr. Wolfgang Stehr
In this episode of BackTable ENT, Dr. Gopi Shah discusses a lean approach to pediatric airway foreign body aspiration with Dr. Wolfgang Stehr, a pediatric surgeon and medical director of surgery at Presbyterian Healthcare in Albuquerque.
BackTable, LLC (Producer). (2023, March 14). Ep. 96 – Airway Foreign Bodies in Children: Risk Reduction [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Wolfgang Stehr
Dr. Wolfgang Stehr is a pediatric surgeon and medical director of surgery at Presbyterian Healthcare in Albuquerque, New Mexico.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
First, the doctors discuss the typical presentation of a pediatric patient who has aspirated an object. They agree that the most common scenario is a toddler choking on a nut, but older kids can also be affected. Dr. Shah notes that although severe aspiration cases can result in respiratory distress, most patients often look fine upon arrival to the ER. For this reason, an experienced clinician should listen for whistling sounds from the bronchi or the lack of breath sounds. Because X-rays can fail to visualize the object, witnessed history of a child choking is very important to consider. Differential diagnoses include reactive airway disease, asthma, pneumonia, and a viral URI.
Next, Dr. Stehr discusses how he implemented the lean process improvement system into the foreign body aspiration bronchoscopy procedure at his hospital. He was motivated to develop a more efficient process after realizing that the most difficult part about a bronchoscopy was putting together the equipment. The lean system is built on the principle that there needs to be a correct order for standardized steps in a procedure in order to reduce waste and train staff more efficiently. He used the “5 S’s” to organize the equipment in the ENT cart, which stands for: sort, set an order, shine, standardize, sustain. Additionally, he gives tips for physicians wanting to start their own quality improvement programs, such as including staff in decision making, having the most resistant stakeholder in the room first, prioritizing the case of patient safety, and inviting collaboration between different specialties when appropriate. He mentions that it is helpful to have a lean expert guide the quality improvement process in the beginning; eventually this third party consultant will train an internal employee to manage the lean process themselves. He also discusses the kaizen workshop, in which his team broke down a process, evaluated each step, and put it back together in a more efficient way. PDSA (Plan, Do, Study, Act) is another helpful framework he recommends.
Finally, he discusses how he measured the efficacy of his lean intervention. He used surrogate measures of time and success, which included watching techs and nurses assemble bronchoscopy equipment while timing them and seeing how many drawers they had to open to gather all the materials. Although he had favorable results, he emphasizes the importance of always being open to new ideas for improvement.
[Dr. Wolfgang Stehr]
Exactly. Kaizen means you take a process, you break it apart, and then you put it back together better. That can be a process, it can be a thing, but it's really about really breaking something down into small bite size pieces and then putting it back together. The question is always, is this a valuable element of this process? Would a parent want you to spend time on this? Would a parent or a patient want you to spend money on this? Would an insurance company want to pay for this? It's like you say, "Oh, we have a great new waiting room. The waiting room can hold 30 people. It's great." Actually, it's not great at all. Why do you need 30 people in your waiting room? That's a waste of their time. It's a waste of space. Maybe you could have an extra exam room instead of having your waiting room. Let's really challenge whether waiting rooms are a good thing. Sometimes they are. We all learned through the pandemic when the airlines broke down, all of a sudden you needed waiting space in the airports. It's difficult. Same with inventory management. One of the things about Lean is, let's make sure you limit your inventory to what you need, until a pandemic comes and we all run out of face masks.
It's something you really have to look at critical, but what happens in the kaizen workshop is you have a standardized process where you invite the right kind of people and teach them enough about the Lean process so that they can engage. Then you actually level set the expectation for the people where everybody has the same voice, which means if you have the chair of surgery and you have an OR nurse and you have sterile processing technician in the room, they all have the same voice because they know their area the best. If the person from sterile processing says, "I have an idea and this would work great for us because it would fit in our washers or would fit in our sterilizers," then let them run with it because people love their own ideas. If you let them run with their idea, then they'll be able to actually make sure that idea is successful. It's easy to take somebody else's idea and quickly think, "Well, that's never going to work. If that's what we're going with, I'm going to make sure that I'm right and it's never going to work." Make sure people can run with their own ideas enough to support it.
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