In Depth Series: Airway Management Proficiency

In Depth Series: Airway Management Proficiency

Airway Management is a critical skill for Emergency Physicians, and competency is a requirement included in every hospital’s Delineation of Privileges credentialing and application process. As a responsive and knowledgeable partner for both our facility and physician partners, ACUTE CARE, INC. works closely and continually to monitor competency and assist clinicians in achieving long lasting and useful skill retention.
The breadth of the Airway Management topic is such that I am going to narrow the focus to one essential element of that skill set, endotracheal intubation.
Even that sub-topic is broad enough to encompass medication-assisted intubation, difficult intubation, video laryngoscopy, and many other important facets of the procedure.
I have elected to address endotracheal skill acquisition, competency evaluation, and skill maintenance, as this specific topic set has essential pertinence to our practices.
As we set the stage, the first question that comes to mind is, “How often do Emergency Physicians intubate? ” The answer, of course, is “It varies”. Thankfully, there is research on the topic.

The Annals of Emergency Medicine published Procedural Experience With Intubation: Results From a National Emergency Medicine Group, which includes this abstract

Study objective: Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation performed by emergency physicians in a national emergency medicine group.

Methods: Using data from a national emergency medicine group (135 emergency departments [EDs] in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations).

Results: We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016). Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6).

Conclusion: These findings provide insights into the frequency with which emergency physicians perform intubations.

Armed with an estimation of the frequency of intubation, we next turn to the question of competency, and how frequency of performance affects the probability of successful intubation.
Again, research on the issue provides some guidance.
The Western Journal of Emergency Medicine published Skill Proficiency is Predicted by Intubation Frequency of Emergency Medicine Attending Physicians, which includes this abstract:
Introduction: Airway management is a fundamental skill of emergency medicine (EM) practice, and suboptimal management leads to poor outcomes. Endotracheal intubation (ETI) is a procedure that is specifically taught in residency, but little is known how best to maintain proficiency in this skill throughout the practitioner’s career. The goal of this study was to identify how the frequency of intubation correlated with measured performance. 
Methods: We assessed 44 emergency physicians for proficiency at ETI by direct laryngoscopy on a simulator. The electronic health record was then queried to obtain their average number of annual ETIs and the time since their last ETI, supervised and individually performed, over a two-year period. We evaluated the strength of correlation between these factors and assessment scores, and then conducted a receiver operator characteristic (ROC) curve analysis to identify factors that predicted proficient performance.
Results: The mean score was 81% (95% confidence interval, 76% – 86%). Scores correlated well with the mean number of ETIs performed annually and with the mean number supervised annually (r = 0.6, p = 0.001 for both). ROC curve analysis identified that physicians would obtain a proficient score if they had performed an average of at least three ETIs annually (sensitivity = 90%, specificity = 64%, AUC = 0.87, p = 0.001) or supervised an average of at least five ETIs annually (sensitivity = 90%, specificity = 59%, AUC = 0.81, p = 0.006) over the previous two years. 
Conclusion: Performing at least three or supervising at least five ETIs annually, averaged over a two-year period, predicted proficient performance on a simulation-based skills assessment. We advocate for proactive maintenance and enhancement of skills, particularly for those who infrequently perform this procedure. [West J Emerg Med. 2019;20(4)601-609] 
This is, however, far from prescriptive. In an effort to support our affiliated clinicians’ goal of consistent success in this critical skill, we are always exploring the options for skill refinement and making available opportunities for impactful continuing education specific to endotracheal intubation. 
Again, the research available provides insight into the methodology to support this effort.
There are no objectively defined training requirements for emergency airway management for the UK emergency physician at present. The current debate provides an opportunity for the development of specific learning objectives for airway management, with clear training objectives for higher specialist trainees in emergency medicine. The following suggestions are based on current practice but take into account the comments made in the literature reviewed. They also take account of Nicol’s previous work on the consensus curriculum for anaesthesia for emergency medicine trainees (personal communication). No attempt has been made to define minimum numbers of procedures, as the available literature cannot support such a suggestion.

Maintenance of these skills will not be easy for the practising consultant in emergency medicine but one possibility is suggested below. Again, these are distilled from the current published literature but questions about optimum or minimum numbers of procedures or sessions remain and require further research.

Skills maintenance programme for consultants in emergency medicine

  • Personal log of all intubations/airway interventions
  • Regular human simulator sessions
  • Regular sessions in local hospital anaesthetic room
  • Ongoing departmental audit of critical airway interventions
  • Combined anaesthesia/intensive care/emergency medicine reviews of cases
As an accredited provider of Continuing Medical Education (CME), ACUTE CARE, INC. has designed didactic and experiential learning opportunities that address Airway Management competency.
We recognize that each clinician’s experience and expertise is unique, and have tailored individual programming, counseling and referrals that ensure that the physician is competent and confident in the performance of this, and other critical lifesaving skills.

Paul Hudson, FACHE
Chief Operating Officer