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.

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SHOW NOTES

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.