Improving Bronchoscopy Safety and Diagnostic Yield in Lung Transplant Recipients

Abstract

<h3>Purpose</h3> Bronchoscopy is invaluable in the diagnosis of airway complications, infection, and rejection in lung transplant recipients, and a fundamental skill in pulmonology fellowship training. We aimed to improve bronchoscopy safety and diagnostic yield in our teaching institution by targeting two quality metrics: 1) higher patient radiation exposure in fellow-assisted compared to attending-only procedures and 2) variability in documentation of exam findings. <h3>Methods</h3> Using an A3 lean approach, we assessed current conditions by retrospective review of lung transplant bronchoscopies over four months. Then, we established target conditions of 1) radiation exposure in fellow-assisted procedures ≤ 2 times that of attending-only and 2) standardized documentation per ISHLT airway grading. Next, we conducted a gap analysis to identify root causes and implemented countermeasures over twelve months. <h3>Results</h3> In current conditions, the mean radiation exposure in fellow-assisted bronchoscopies was 2.6 ± 0.3 times higher than attending-only. We targeted fluoroscopy duration, lack of knowledge, and variable feedback with these countermeasures: tracking of fluoroscopy exposure, self-assessment of bronchoscopy competency, access to a fluoroscopy education video, and post-procedure attending feedback. As a result, radiation exposure ≤ 2 times was achieved in 11/12 months (92%). In current conditions, documentation included ischemia, malacia and stenosis in < 20% of bronchoscopies. We targeted lack of knowledge by creating a templated bronchoscopy report with multiple choice options to document ISHLT airway grading and placed representative graphics in the bronchoscopy suite. As a result, dehiscence, ischemia, malacia, and stenosis were documented in > 80% of bronchoscopies. <h3>Conclusion</h3> We successfully reduced radiation exposure difference in fellow assisted bronchoscopies and reduced variability of bronchoscopy documentation by implementing multiple countermeasures using an A3 lean approach.