BackTable / ENT / Podcast / Transcript #96

Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Presentation & Diagnosis of Airway Foreign Bodies in Children

(2) Equipment Management in Airway Foreign Body Extraction

(3) Applying the Toyota Lean System to Pediatric Foreign Body Management

(4) Implementing the Lean Methodology: Stakeholder Engagement

(5) Exploring Teamwork Dynamics in Lean Implementation

(6) An Overview of Kaizen Workshops

(7) Measuring Efficacy in Medical Equipment Management

(8) Streamlining Equipment Management through Cross-Speciality Collaboration

(9) Continuous Improvement in Medical Equipment Management

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[Dr. Gopi Shah]
Hello, everyone, and welcome to The BackTable ENT podcast where we discuss all things ENT. We bring you the best and brightest in our field with a hope that you can take something from our show to your practice.

My name is Gopi Shah, and I'm a pediatric ENT. We're discussing a very important topic today, airway foreign bodies in children and risk reduction using the lean method. My guest today is Dr. Wolfgang Stehr. He's a pediatric surgeon and the director of surgery at Presbyterian Health Services in Albuquerque, New Mexico. He has a passion for quality and leadership, and he's here today to talk to us about his experience with pediatric foreign body aspiration and risk reduction with lean management. Welcome to the show, Dr. Stehr. How are you?

[Dr. Wolfgang Stehr]
I'm great. Thank you for having me.

[Dr. Gopi Shah]
Before we get into it, can you tell us a little bit about yourself and your practice?

[Dr. Wolfgang Stehr]
Yes, I'm a pediatric surgeon, and I have been the medical director over operating rooms and now medical director over surgery for about 10 years. In that role, one of my key goals is to improve safety, improve access, improve efficiencies in and around the operating room for the surgeons, but of course for the patients.

[Dr. Gopi Shah]
Absolutely. Can you tell us a little bit, I know you have an MBA and how you decided to pursue that, and how that fits in with your role?

[Dr. Wolfgang Stehr]
When I first started in the OR surgery director role, our organization started on the Lean journey and incorporated Toyota Lean into the management process. After doing numerous workshops and years of process improvement, I realized that process only takes you to a certain place and only leadership and people will then take you beyond process to higher level quality. That's when I decided I needed additional training and I got the MBA. It really focused a lot on leadership and people.

[Dr. Gopi Shah]
What we're going to talk about today, airway foreign body in children, and then we're going to tie that in with the Toyota Lean process. Let's go ahead and set the stage for our listeners because I think that what's great about this conversation is, one, we have pediatric ENT and we have you, the pediatric surgeon. What's nice is that we're both talking about this because depending on where you are, either both teams are handling or one or the other. It's something that we are able to work together on, especially with something that can be very tricky, can have high stakes, and then there is high risks at the end depending on how the case goes. Just to set the clinical stage for our listeners, how do these kids usually present to you? What have you seen?

(1) Presentation & Diagnosis of Airway Foreign Bodies in Children

[Dr. Wolfgang Stehr]
In our hospital, we did have pediatric ENT and we do have pediatric surgery and we were a trauma center. We always had pediatric surgeons on call in the house to take care of trauma patients and emergent acute patients. Children with airway foreign bodies, it's oftentimes the toddlers, they eat the nuts, which they're not as supposed to eat and then they aspirate the nut and they come in with a story of the parents sometimes saying, "I think he ate these nuts and he coughed for a while, but now he looks good." Then they end up in the emergency room. The emergency room doctors, they get an X-ray, which usually doesn't show anything, and if they're lucky, they'll listen to the child and hear some whistling in one of the bronchi. Sometimes you actually have the worst-case scenario where you have a child in significant respiratory distress.

[Dr. Gopi Shah]
Absolutely. I think what you describe is pretty common. I agree. It's mostly toddlers, although sometimes they can be quite young, under one, I've seen, and it can be even older kids that don't tell you about an incident that they had. I think you hit the nail in the head, they oftentimes look fine. Fortunately, most of the kids don't come in acute respiratory distress or extremis.

The clinical decision-making can be difficult if there wasn't a witnessed history of choking or maybe it happened and the x-ray most of the time looks fine. We'll get the lateral decubitus, see if there's any ear trapping, if there is a foreign body or something obstructing the bronchi. A lot of times it looks fine, and I think what you said, if they were lucky, the ER physician or maybe the pediatrician or somebody may hear something like wheezing or stridor, subtle stridor or if it's been a while, maybe [unintelligible 00:05:51] sounds on a single side. Again, those clinical physical exam and X-ray findings aren't always there, so I would say the witness history for me is very important as well. Do you ever get a CT, is there ever an indication for you to get a CT for a concern for an airway foreign body?

[Dr. Wolfgang Stehr]
Yes, we would get advanced imaging if there was a chronic history. If there was maybe a remote history of possible aspiration with a coughing event, normal physical exam, and then sometimes development of a pneumonia that then shows the lobar or subsegmental area in the lung that just isn't aerated well, then we would get the CT scan. The wildest thing we've seen there was a pea that actually started to sprout in the airway. You saw this little piece of leaf already growing out of that pea, which then we took out with a bronchoscopy.

[Dr. Gopi Shah]
Wow. I agree that ties into the differential diagnosis or the things that can masquerade or [unintelligible 00:06:58] the red herring or cover the diagnosis of a foreign body that then leads to a pneumonia. A lot of kids will, "Well, they've been treated for reactive airway for the last three months," or, "Oh, they have asthma," here we are intubated, right lung out and there's actually a peanut or something else there. Sometimes in the infants, if there isn't a strong history or maybe there is a little history in the 15-month-old of, "Yes, they coughed a little bit when they were eating a chip," and now they're coming to the ER and there's a runny nose. Sometimes that can be hard to decipher as well. Is it a viral URI, is it mucus plugging or how does it all go? These can be really tricky to tease out sometimes, especially with the history, I think is the most important thing regardless, meaning, if there's a witnessed choking history, they coughed, there was a time where potentially they stopped breathing or turned blue, is going to be your biggest reason to go to the OR to take a look.

Now planning for the OR, tell me what your thoughts are and why just planning or thinking about the or, it's like, "All right, here we go."

(2) Equipment Management in Airway Foreign Body Extraction

[Dr. Wolfgang Stehr]
When I was doing my pediatric surgery fellowship, one of my attendings says the hardest thing about a bronchoscopy is putting together the equipment, because oftentimes this happens evening, off hours, weekends, or at night, and you don't have the A team that is trained and experienced with your ENT procedures or with your bronchoscopy equipment.

More often than not, there was always the stressed hunt for this little piece, that connector that was missing, or you'll usually have the light cord and you'll have the lens, but then do you have the right grasper and do you have the right length of the lens that fits into your scope? Do you have the right visual grasper with the right lens that fits in the grasper that then fits in your scope? It felt so unnecessary to do this last minute when everybody's already on edge and a little stressed and you're trying to take care of this patient.

[Dr. Gopi Shah]
Absolutely. My thought is half the case or the success of the case really depends on how the setup is, how prepared you are, is the equipment ready, and have I talked to my tech, my nurse, and my anesthesiologist. As much information as I have, the child looks clinically great or the child is really struggling to, hey, the family said it was from after they were eating a bowl of popcorn and maybe I can somehow practice with something round and smooth to grab it to talking to my tech of, "Hey, this is what they think it is."

If I can't get it with my grasper, do we have access to a basket, does it slide in? Do I have a potentially even a balloon or what are different ways because plan A doesn't always work and we sometimes have to get to plan C. As much as the setup is very important, talking to our anesthesia colleagues, but I think that these happen at off hours, middle of the night, weekends, holidays. It's not always going to be the anesthesiologist that you've done your airway cases with. It's not always going to be the tech that knows the ENT, ENT lead tech that knows where all the little bits and parts that you need are, and it's not always the nurse that's used to bringing this child with an airway foreign bodies up from the ER or from pre-op and knowing how to arrange the room and everything that we need. I think the one constant, though, is having the right equipment. That's the one thing that we can try to make sure that we have, because how many times have you put in the grasper and maybe the tines are slightly off and you just can't grab it or the peanut grasper that you need, it doesn't stay open or it doesn't close right and the child's on the table. That's the worst feeling. That drives me crazy.

[Dr. Wolfgang Stehr]
Yes, you're right. This is one of the things that motivated me to lean into this and actually try to provide a better option. Maybe one little thing, many of us know that this equipment sometimes lives in a big cart that has multiple metal drawers and you have one drawer that's supposed to have the graspers, you have one drawer that's supposed to have the scopes, and another drawer that's supposed to have the suction devices, and then the light cord and the section tubing are somewhere else because they left with the laparoscopy equipment. You talked about those option B and option C and sometimes option D, somehow it makes us feel safe to have access to everything. That's why people love the big carts, because the cart has everything, like 100 different options and 100 different graspers. Reality is, those multiple elements of the bronchoscopy equipment are not maintained and are very hard to see and identify when you really quickly need to put together your scope and get the right grasper. That was the starting point where we said, "Let's make this better."

(3) Applying the Toyota Lean System to Pediatric Foreign Body Management

[Dr. Gopi Shah]
Tell me about the Lean methodology. What is the Toyota Lean System? How'd you learn about it?

[Dr. Wolfgang Stehr]
The organization I worked with actually embraced Toyota Lean as their process improvement system. A simple way to describe it is, if you put together a car and it's your job to put on the wheels, then the step that has to happen before you put on the wheel, you have to put in the brakes. You have your car, you put on the brakes and then you put on the wheel. If somebody does it in the wrong order and you put your wheel on and you maybe forget your brakes, you know something is going wrong when this car rolls off the lot. Same thing in healthcare, there is a correct order for the process and you have to do step A and then you have to do step B and then you have to do step C. Many of those processes can be very standardized in order to make it easier and more efficient and not have to rethink it. It also really helps training the staff on saying, "This is our process, this is how we do it, because it's more efficient and it's safer."

[Dr. Gopi Shah]
Why was this process-- Why did you apply this method specific to airway foreign bodies in children?

[Dr. Wolfgang Stehr]
Look, many articles in the past 10 years have written about there being so much waste in healthcare. There's a number of things we're wasting. We're wasting time, we're wasting equipment, we're wasting motion, we're wasting inventory. The organizations then bring in Lean because they think it can save them money. That is true. Besides saving money, we can really improve safety and quality of the process. We took the Lean methodology and looked at these airway foreign bodies and the equipment that we use to take care of those children. It fits into the process very nicely. We can go through some of the steps if you would like.

[Dr. Gopi Shah]
Absolutely. I would love to hear about the steps.

[Dr. Wolfgang Stehr]
We start with first identifying a goal. What is it we actually want to do. For this, we want to take better care of patients with airway foreign bodies. Then we identify further who are these patients? Are they really all under a year old? Are they really under two years old, or are there some teenagers? We look back at our data. The data actually said, yes, there's a peak early on between 9 and 20 months. Then there's a few other patients that are a little bit older. They're teenagers. They put stuff in their mouths like a nail or sometimes a sewing needle, push pins,

[Dr. Gopi Shah]
Push pins.

[Dr. Wolfgang Stehr]
Exactly.

[Dr. Gopi Shah]
Yes, I've had that too.

[Dr. Wolfgang Stehr]
They need different equipment. Already being able to separate by age or by weight, allows you to have two completely different setups. Then one of the important elements of the Lean process is you go through the 5S steps. The steps are you sort, you set in order, you shine, you standardize and you sustain. What does that mean? Sorting means you open your big cart with all your drawers and you touch every single item that's in there and you make sure you have what you need and you can throw out the stuff you no longer need or nobody has ever used, and then you set in order. Setting in order is exactly what you said. The little alligator grasper and the tines don't meet. That is setting in order, making sure that the equipment that is in your tray actually works. Then shine is, you make sure you have the right way to clean it and you have the right way to maintain it, because sometimes you have your scopes and you look through it and in there, there may still be a tiny little bit of piece of dried blood or something, and that shouldn't be, same with your lenses. The lenses have to be straight, they have to have a full vision. We have to make sure they're maintained. Then we standardize, which means we find a way to take care of this equipment the same way every time, whether you have a traveler in sterile processing or whether you have a new tech or whether you have a visiting surgeon who's doing this procedure. We really try to standardize the process and then come sustain. Sustain then allows us to maintain the equipment so that if I come back in a year, it's still taken care of the same way, and that the right people touch it and those people who touch it know what to do and know what to expect and then the equipment is put together. These are the 5S of the lean process.

(4) Implementing the Lean Methodology: Stakeholder Engagement

[Dr. Gopi Shah]
They make sense and I love that the 5Ss are very helpful in terms of how to think about it and how to make something better. In terms of sorting, who's involved? Because for each S, I feel like there's going to be different players involved. We can talk about that in a second too, because you, to change something up, need to get buy-in. Before we get into that, tell me who's involved just with the first S of sorting.

[Dr. Wolfgang Stehr]
The way we did it, we actually learned that we have to have all the stakeholders together, because if people feel excluded, they will not buy in and they will not participate in the sustain. Because like, "Oh, this is this new thing the administration is doing for this stuff and they don't even know what we need." You need to have the stakeholders in the room. Sometimes it is really helpful to have the most resistant stakeholder in the room very early on. Because getting them on board at the end is really difficult. What we do is, we make the safety case first. Because it's hard to get somebody to disengage when you actually talk about making it easier and better and safer for them and for their patients.

[Dr. Gopi Shah]
That's so smart. I think that first S in getting the most resistant or the one that may not early on, and then that why, being able to drink the same juice for why we're doing it, which I think anybody would agree that the patient safety, these cases are hard. It could have a detrimental outcome, one that could be prevented too.

[Dr. Wolfgang Stehr]
Then for this particular set of tools, we also had to look who actually uses it. It was the pediatric surgeons who use it. There were also the pediatric ENT surgeons who use it. We needed to have participation from both sides.

[Dr. Gopi Shah]
How did that go at your hospital?

[Dr. Wolfgang Stehr]
It was ultimately smooth and easy, but initially, if you have a chair or division chief of one department and then a personal representative from the other department, especially when they're short staffed, it's really hard to say, "Oh, I don't have time to do this." I don't have time to spend the whole day looking at your equipment. Then we really had to see, "Okay, we don't need a whole day. Let's see how much time do we actually really need from you." What we did is, we did set up this sorting process in an empty operating room next to the pediatric ENT's operating room. While they were between two cases, we could grab them for 30 minutes, and they came over and they looked and see and so they could give their input. That already was enough for that particular step. We also have to be very mindful of how much time do people actually have and how can they add value to the process improvement.

[Dr. Gopi Shah]
That makes sense. I think that's great, because when it is collaborative, which I feel like pretty much every part of medicine is. It's collaborative and multidisciplinary to make things-- Whether it's foreign bodies to pediatric thyroid, anything that overlaps, I think that when you have people at the table that work together, it just makes the process, the outcomes. Also, I feel like your own experience as a physician, a caretaker, when you have a team member that you can talk to each other. We talked about sorting. Who is involved in setting the order? At what point do the OR techs or the FPD? Was the OR tech part of your sorting as well?

(5) Exploring Teamwork Dynamics in Lean Implementation

[Dr. Wolfgang Stehr]
I was maybe not very clear on how we put together the team and how we decide on the team. Usually there is a Lean expert, there's a person who understands the Lean methodology, who understands the different process steps. They already do a lot of groundwork before the Lean event actually starts. They review and interview all the different groups of people who may be involved in the process. There's the OR tech, there's the OR nurse, there's the person from central processing or sterile processing, and there are the surgeons. Not particularly this one, but in some Lean improvement workshops, we actually included the parents because we wanted them to be at the table to say this is what better would look like for us. You have the whole team and that team then comes together and we did sometimes two or three days of workshops in a row where on Monday we would say, "All right, this is our goal, this is what we're working with. Let's go out and look at the workplace, look at the place where the work is actually done and see what the reality is. How this equipment is being used, how this equipment is being stored, and who all touches this equipment in real life."

We're not trying to take a problem, take it out of the work area and move it into some back office and try to fix it in the back office. One of the key elements of Lean is you have to go look and see where the work is being done and that's where you're going to improve it, and that's where you're going to fix it, because otherwise, it's always people bringing their story or their part of the story into an office and you never get the whole story.

[Dr. Gopi Shah]
That makes sense. How important, in this situation, was it also to-- did you need to get hospital buy-in or any administrative level buy-in for something like this?

[Dr. Wolfgang Stehr]
Yes, because we take a few people offline and they are not doing their job. They're doing improvement work. Hospitals who engage in Lean methodology, they know that it takes the investment of taking folks offline to do this work in order to make improvements. In an ideal Lean world, about 3% of your workforce should be involved in Lean work. Sometimes that's a small portion of nurses that do a few hours so that over the year, maybe that's about 3% of their time. That's the investment the organization has to make. We were lucky we had an administration that embraced that process. They wanted this and they wanted us to be safer and better and of course save money.

[Dr. Gopi Shah]
No. That makes sense. In terms of having the Lean expert there to guide the process, who is that? Is that the chief quality officer of the hospital? Is that an external third-party consultant? How does that work?

[Dr. Wolfgang Stehr]
For most organizations, it starts with a consultant, and they come from the outside. Then they start to train people on the inside and ultimately the process can be run on the inside. I became trained to be a Lean expert and physician champion in the organization. After a few years of doing it, I was able to run the workshop, help prepare the workshop, but then it really also is helpful to have a Lean office because they then can help with the sustain, they can help gather the data, they can help see what impact did this actually make. There's multiple elements. Training people on the front-line to own the process is much more helpful and then feels much more natural because we've all experienced this. Some consultant comes, they don't know the organization that well, they don't know you that well, they don't know your processes that well. They start with asking a lot of questions. You already have the answers, so you don't really need them because you are the one who has the answers.

[Dr. Gopi Shah]
No, I think you make a great point. I think whether it's an outside consultant or any new person, whether they're in leadership or new to your department colleague, there's a lot to still learn about where you are. That's going to come from listening to those who've already been there who are like you said, on the front-lines so that you can actually, as opposed to just coming in and saying you've got to do this and this and this, because nobody's going to listen. They're not going to listen to that. Can you tell me a little bit about the workshops? I had seen something about the kaizen workshops.

(6) An Overview of Kaizen Workshops

[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.

Then that's another element of the kaizen workshop where on day two or day three, you actually try out the new process. You actually pretend you go through a case and you try it out. Then you very quickly learn, this is better or this is not as good as I thought. Then you iterate on it and you do give it another try. You think about it again. Some people also talk about the PDCS circle,

[Dr. Gopi Shah]
The PDSA, Plan-Do-Study-Act?

[Dr. Wolfgang Stehr]
Correct, same thing. You have an idea, you try out the idea. If it's not as good as you want it to be, you go back around and you study it again and you look again and you change it again.

[Dr. Gopi Shah]
Absolutely. I think that's great. I think for anybody listening, what you just said about bringing everybody to the table and having the level expectation is that's a leadership role right there in terms of trying to make anything better. Bringing everybody, including them, and listening to what their thoughts on their domain is. That's a leadership pearl. In terms of measuring your intervention, we just touched on that. How often do you do that with a new intervention? Then let's say it's now been two years at the hospital with this intervention, how often do you do it then? How does that--

(7) Measuring Efficacy in Medical Equipment Management

[Dr. Wolfgang Stehr]
Great. That's a really important question because we can only improve what we can measure. In this particular process, we looked very hard to see what are things that would actually show that we are doing better. We had three different measures. The first one was, can a nurse or a tech put this thing together so that it works? The second one was, how long does it take to put the equipment together? The third one was, how many drawers do you have to open in order to put this equipment together? The opening of the drawers in this big metal cart was a surrogate of how efficient is it put together.

When we started, I walked around and I asked 10 nurses, I said, "Hey, please put together a bronchoscopy set for a one year old kid." I had my stopwatch and I clicked and I watched them do it. It would take them 10 minutes. Out of 10 nurses, one was able to put this together, and they had to open an average of about 10 drawers, because you open the first one, it's not in there, you close it, you open the next one and it's still not in there, you open the first one again and finally you find it. Those were the three things. When we started, it took a long time. The ability of actually creating a functional setup was almost zero. Numerous drawers had to be opened.

[Dr. Gopi Shah]
Can the staff put it together, how long does it take, and how many drawers, how did y'all pick those as your outcomes to measure?

[Dr. Wolfgang Stehr]
It was hard to say, oh, how much money can we save when we do a better job because there's no dollar sign on your drawer. You sometimes need to really look and see, okay, what is a surrogate measure of time or a surrogate measure of success in order to look and see whether you're doing is better or not, because then on the back end, where we arrived, was I asked 10 nurses whether they could put it together and all 10 of them were able to put it together. It took 2 minutes and they had to open zero drawers. That was an improvement.

[Dr. Gopi Shah]
Then how often do you feel like people need training in putting the equipment together, because again, this isn't a high volume, this isn't doing tonsils, 10 tonsils in a day, 5 tonsils a day, and 10 tubes. They're frequent enough, but they're not once a week. How often do you have to train?

[Dr. Wolfgang Stehr]
Very important that you talk about education. The people who are engaged in the process, in the workshop, they know what to expect and they know, "Oh, we're doing this differently now." There are other people who have to touch it. There are other people who have to touch the equipment and so an important part of every kaizen workshop is a education plan. On the education plan, you have, what do people need to be educated on? Who are those people? You write them down by name. It's like, all of our 15 central sterile processing department technicians need to know, all of our nurses need to know, these are their names, and this is the person who is responsible to train them.

Then you go around and you check the box, you say, okay, this person was trained, they can do it to be somewhat proficient at it, and this person, because they work in the ENT room every day, they are an expert at it. You actually know, okay, these people need to be trained, these people were trained, and then most important thing, you write a document that is called a standard work document. Standard work can either live with the equipment or can live in sterile processing or can live in the operating room, where if you have a traveling nurse who knows nothing about your organization, they open the folder on standard work and in there they will find, this is how we use and put together bronchoscopy equipment, they can look at it, sometimes there's photos in it, sometimes there's drawings in it, so that even if they know nothing about your organization, they know nothing about pediatric bronchoscopy, they can still put it together.

[Dr. Gopi Shah]
In the moment, this folder is easy to use with a few minutes of understanding in the moment because I can't imagine that being on day one of orientation of the traveling tech or nurse for a procedure they may or may not have to experience.

[Dr. Wolfgang Stehr]
Exactly. That's another very important element of Lean management, which is making things visual. We call it visual management, so that the ENT cart doesn't have this tiny little three letters in the corner, ENT cart. It should be bold, it should be clear, it should have the right color. It's like, this is the ENT cart. Then you may have either a folder or some laminated sheets hanging on the side and you can pick it up and on there it's like, bronchoscopy. Then you look it up and all the information you need, how to put it together, is in there.

Same with the equipment. We're going to talk about that in a minute, I guess. The equipment will be managed differently, so people can really visually quickly understand this is the ENT cart, this is how I do a bronchoscopy. They look through the drawers or the trays and then they see, "Oh, this is bronchoscopy."

[Dr. Gopi Shah]
I see this system being applied to, potentially, sinus surgery and navigating systems especially if you're at different hospitals, or let's say there's a change, having a visual handbook handy, because again, some of those cases aren't always during the weekday with the "A team." Let's talk about the equipment. Tell me about the equipment.

(8) Streamlining Equipment Management through Cross-Speciality Collaboration

[Dr. Wolfgang Stehr]
We actually know our equipment, but we don't know everything. You know what you know and you know what you use, but there are people out there who are better at it. We actually engaged some people from the industry. Bringing industry in actually was helpful because they have additional knowledge, but they can also learn from the work we do and can then share it and make it safer for other organizations. One thing that was really interesting, we thought we need to put this equipment into a more contained space so that it's not five drawers. What if this was just one tray? All our other operating equipment, it comes in trays, the trays get sterilized, you open the lid and you see here are our graspers, here's our pickups, here are our clamps, and why not do the same thing for the bronchoscopy equipment?

They then said, "Oh, we are doing the same thing for urology procedures because they have scopes and lenses and cameras, and things that look very similar to your bronchoscopy equipment. Let's use a cystoscopy tray and see if we can just convert that into a bronchoscopy tray." Then there were little holders that hold up your scope that doesn't roll around and it doesn't fall and it doesn't break, and then there were other little holders where you could have your graspers and if it's managed right, you look at that tray and you immediately see everything is there or something is missing.

You open the tray and we also had the things I described, the grasps, the lens, the scopes, and then we had an additional little box in there that had all the small items. The small items are the little connectors, and the connector to the light cord, and the little spacer, they had their little box. You open the box, you're like, "They're all here. They're all there," and it creates such a sense of comfort and trust knowing that, "Wow, everything's here. We can just put it together and we're going to be okay."

[Dr. Gopi Shah]
Yes, I think that's a great-- Collaborating with industry can be helpful, like you said, because they can pull in experience from another specialty and how their equipment is-- and also see where, "Hey, our scopes are always breaking." When it transports SPD, maybe there's a different box or setup or something to help even with that kind of process. I think that's great. This sounds like this is really good for plan A, because I feel like majority of the time, 95% of the time, 99% even, plan A is what works. You have your optical forceps, your graspers, you have your scopes, you have your age appropriate [unintelligible 00:37:05] you have your suction. Is the Lean system helpful for the plan B and C or in Lean system, do you want to just make sure you have plan A right and then go from there? Tell me about the nuances or variabilities.

(9) Continuous Improvement in Medical Equipment Management

[Dr. Wolfgang Stehr]
I'm glad you asked that because that's oftentimes the hesitancy of some of the users to engage in Lean. They said, "Well, but one time I had this very difficult case and I needed this one particular grasper and you cannot get rid of it. You need to have it there."

[Dr. Gopi Shah]
We're so anecdotal in our practice, right?

[Dr. Wolfgang Stehr]
Absolutely right. That's exactly what happens. We said, "Yes, we will not throw out your one-time grasper. We will make sure it is available to you," and we created an additional box, an additional tray that had the one-time instruments in it. It would live there and it would not have to be opened. They would not have to be re-sterilized. They would not break because they lived in their own little space.

You have an additional set of equipment that is rarely used and we actually labeled it after the physician who really demanded it. This was Dr. [unintelligible 00:38:23] box, and it would live in its own little space, not in the prime space because prime space should have the prime equipment, but it lived on the new cart. It was always there and as long as I worked there it was never used. It was opened a few times because people felt like there was stuff in there they could use. That's where you really have to cater to people's fears because if you as a surgeon feel like they're taking away stuff that makes you feel safer, we are not doing a good job. We need to make sure that the users feel safe, and if it takes an extra tray, so be it.

[Dr. Gopi Shah]
That's a good point. I have to shout out Dr. [unintelligible 00:39:06] because I get it. There's a few things, depending on whatever case, we like to have those things. It's nice to be able to collaborate and see what you actually need and go from there and then know if you do need something in your back pocket, it's not completely gone or taken away. Have y'all had any changes since your initial implementation? Anything that a year later, two years later that y'all switched out or anything you would've done differently in terms of setting up the Lean process for this project?

[Dr. Wolfgang Stehr]
Yes. The process does not end at the end of the Lean week. The process goes on. Whoever uses that equipment, when they come back with an improvement idea, we consider it, and then we can actually build it in. A couple things we did was in the end, we ended up with trays that have clear lids, and you don't have to open it to actually see what's going on. We also iterated a couple times on do we need to go by age or do we need to go by weight? Because your 10 kilo kid could be short and chubby and just not very tall. While they sometimes need different equipment, the problem is, when I call from the emergency room to the operating room and say, "I need to do a bronchoscopy," the nurses who set up your room, they don't know the kid's weight. Using weight as a measurement to decide which tray to open didn't work, they know how old the kid is because they can read it on the board and they can read it on your case request. We went back to age-based trays, and then we also improved the cart ultimately by putting a light source box onto the cart and by putting a monitor on the cart. Ultimately, all you had to do to do a bronchoscopy is drive in the bronchoscopy tower that had all your equipment and your light cable with a Y and your monitor and you didn't need the laparoscopy tower. You didn't need any of that other stuff. We iterated on that and we made it better over the next couple years.

[Dr. Gopi Shah]
That's great. As we start wrapping up, Dr. Stehr, any final pearls or thoughts from your experience with this project?

[Dr. Wolfgang Stehr]
One thing, the way we called it, we created kits where the stuff you need comes in a kit because then all you have to maintain is the kit and no longer the cart. That is a significant reduction of touches, of runs through the sterile processing and just a lot less time is spent because a lot less equipment is actually being opened. The most important thing I think is engage your people, give them a voice, and make them part of the process, because if you don't, they will not engage in the new process.

[Dr. Gopi Shah]
That's a great point. For any of our listeners who might want to learn more about Lean methodology or quality improvement in general, do you have resources that you can recommend?

[Dr. Wolfgang Stehr]
There are so many consultants out there and there are so many books and a lot has been written in the last 15 years. I would just recommend hop on your search engine or go to your bookstore and look and see what is out there. At the same time, there are so many healthcare organizations that are now engaging this that you will find someone who knows something about this and you can have a one-on-one conversation with you. If you can't find anyone, you can reach out to me. I'm happy to have a conversation.

[Dr. Gopi Shah]
That leads me to my last question. If any of our listeners do want to reach out to you, are you on any social media or how would they get in touch with you?

[Dr. Wolfgang Stehr]
I am on LinkedIn and I'm happy to share my email or even my phone number if somebody wants to speak with me.

[Dr. Gopi Shah]
Awesome. Thank you so much, Dr. Stehr. I appreciate your time. I've learned a ton. For our listeners, remember you can find us on Apple, Spotify, SoundCloud [unintelligible 00:43:02] Reach out to us on @_BackTableENT with any questions or if you [unintelligible 00:43:08] come on the show. Thank you.

[Dr. Wolfgang Stehr]
Thank you so much.

Podcast Contributors

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.

Cite This Podcast

BackTable, LLC (Producer). (2023, March 14). Ep. 96 – Airway Foreign Bodies in Children: Risk Reduction [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.