Decreasing Time to Place and Teach Double-Lumen Endotracheal Intubation: Engaging Anesthesia in Lean

Background. This report documents our process to standardize and decrease the time to place and teach double-lumen endotracheal tube (DLETT) intubation. Methods. A prospective database of patients who underwent lobectomy or segmentectomy by 1 surgeon was reviewed. A systematic approach was instituted starting in 2009. A monitor in the room displayed the bronchoscopic view as anesthesia residents were taught how to drive a bronchoscope. The bronchial side was placed above the carina, a bronchoscope went into the desired side, and the double-lumen tube slid over it. A head towel protected the ears, face, and hair, and the DLETT was anchored so that rebronching after turning was eliminated. All other nonvalued steps were eliminated. Results. There were 2,940 patients. Pulmonary lobectomy was performed in 2,421 patients and segmentectomy in 566. Patients were divided into nine cohorts of 350 consecutive patients, except for the last cohort. Median time for DLETT placement decreased from 13 minutes from January 1997 to February 2001 to a median 45 seconds from June 2016 to May 2017 (p < 0.001). Anesthesia residents, present for 76% of the operations, were able to place the tube independently 80% of the time. There were no airway perforations. Conclusions. DLETT placement can be standardized and taught efficiently. Factors that may lead to this are eliminating nonvalued steps (process of lean), engaging anesthesiologists and surgeons to teach team standardization, improved tracheal-bronchial anatomy and bronchoscopy skills in residents, and displaying the intubation and bronchoscopy on a monitor. (C) 2018 by The Society of Thoracic Surgeons