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Critical Care Identifying and Correcting the Performance Errors of Video Laryngoscopy: The Next Step in Emergency Airway Education
Identifying and Correcting the Performance Errors of Video Laryngoscopy: The Next Step in Emergency Airway Education
By Ryan N Barnicle, MD, MSEd; Alexander Bracey, MD; and Scott Weingart, MD on behalf of the SAEM Critical Care Interest Group
Endotracheal intubation (ETI) is one of the most performed high-risk procedures in emergency medicine. For this reason, the Accreditation Council for Graduate Medical Education (ACGME) has set an Emergency Medicine Defined Key Index Procedure Minimum of 35 intubations that must be performed by the time of graduation. Additionally, the ACGME allows for up to 30% of these required procedures to be performed in a simulation environment. Certainly, many residents successfully perform more intubations while training, but this minimum number should seem shockingly low for such a critical skill. Given the limited time constraints of residency training, it is necessary to explore how to augment exposure to laryngoscopy and maximize that educational impact. It is unclear whether the individual opportunities to perform endotracheal
Table 1
ERRORS OF LARYNGOSCOPY BLADE INSERTION ERRORS OF VALLECULA MANIPULATION ERRORS OF ENDOTRACHEAL TUBE DELIVERY
Inadequate suctioning Inadequate lifting force Bougie delivery issue
Entry off midline Failure to engage midline– median glossoepiglottic fold
Insertion too deep Lost seating in vallecula
No anatomical structure recognition Not fully seated in vallecula
Too much force in vallecula View too close
Tube delivery issues
Premature withdrawal of camera
intubation have increased or decreased for residents now training in 2022. With an aging population seeking care in the emergency department for exacerbations of chronic disease, one might suspect that this has increased; however, when considering the widespread adoption of noninvasive positive pressure ventilation and expanding emergency medicine residency class sizes, the chance to intubate may be shrinking for modern day trainees. The truth is unknown and needs to be investigated.
Regardless, exposure to more emergency intubations very likely benefits emergency medicine residents as they strive for competence and, ultimately, mastery of the skill of ETI; however, quantity is not everything. Currently, there is no widely accepted standard approach for quality assurance of actual video laryngoscopy technical skill; rather, we judge laryngoscopy attempts as a binary outcome of “successful” or “unsuccessful” and potentially track the adverse events surrounding intubation (e.g., hypoxemia, hypotension, periintubation arrest). But few receive direct feedback on the quality of the individual components of laryngoscopy which lead to a successful or unsuccessful intubation.
This is an area where video laryngoscopy (VL) technology has the potential to further revolutionize airway education. Routine review of recorded video laryngoscopy attempts can add true quality assessment to every attempt (i.e., perfect practice makes perfect). The evidence supporting the use of VL over direct laryngoscopy (DL) for intubation success is growing and has been summarized in a recent Cochrane review. While the debate for VL versus DL superiority will continue for the foreseeable future, the educational benefit of using VL to improve resident performance remains largely unexplored. It is known that the learning curve for VL is less steep compared to DL during residency training. Still, it is unclear why this is the case and few suggestions have been made formally to address the issue.
One powerful function that is underutilized for teaching purposes is the “record” function present on most modern video laryngoscopy devices. Recording intubation attempts allows for retrospective review of technique in both common and challenging scenarios in a low-stakes classroom learning environment or individualized operator feedback. Important to these discussions, however, is a language for corrective feedback in airway teaching, which is currently lacking.
To this end, we are developing a taxonomy of performance errors with the aim of generating a universal language for airway educators to use when reviewing recordings for pitfalls and providing instruction or feedback to trainees. An extensive analysis of recorded laryngoscopy attempts over the course of several years revealed 13 distinct performance errors of varying frequency that were repetitively committed by the emergency medicine residents at one suburban academic emergency department. Identifying these errors was the first step towards utilizing VL to its maximum potential.
The performance errors identified can be naturally organized into three phases of intubation that should be already familiar to emergency physicians: 1) errors of blade insertion; 2) errors of vallecula manipulation; and 3) errors of endotracheal tube delivery. Interestingly, after excluding error-free videos, identified errors never occurred in isolation but were always present with other errors,
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some with statistical significance. This sample was specifically selected for the presence of performance errors and Table 1 lists each error within our data set.
It is important to note that many of these errors also apply to the direct laryngoscopy technique. While it is true some are unique to the use of video devices, all are certainly more obvious on review of recordings due to the ability to pause, rewind, and replay critical actions for an audience of learners to better appreciate. For example, one of the more commonly seen errors— failure to engage the midline—was recently well described by Driver et al. As that study points out, this is not an error easily visualized with direct laryngoscopy but is readily apparent on video. Since engagement of the blade tip at this precise position increases glottic view, failure to do so is an error that can compromise an intubation attempt; however, it can be mitigated in the future by revealing and reviewing it with trainees as a specific objective to strive for or error to mitigate.
Recorded performance errors are particularly powerful when they occur in the presence of unique situations. For instance, a recorded and reviewed performance error can reveal how best to navigate the manipulation of the omega epiglottis or how to adequately suction during laryngoscopy with massive gastrointestinal hemorrhage. These relatively rare occurrences are amenable to performance error mitigation and perhaps the true benefit lies in collective review of a program’s intubations. This allows both novice trainees and expert operators to see the actual laryngoscopy attempts of their peers. Of course, these should be deidentified and kept in a secure digital library, but the chance to learn about difficult laryngoscopy scenarios preemptively before they are encountered in real life can be a crucial educational tool.
Mastery of emergency intubation goes beyond traditional research metrics like first pass success or time to intubation. While competence may be simplified to failure or success, true mastery is something much more. Laryngoscopy is a procedure that consists of many discrete microskills that require technical precision. Performance errors committed during a laryngoscopy attempt can, expectedly, lead to delayed intubation, repeat attempts, and adverse outcomes for patients. Failing to appropriately respond to difficult factors encountered during a laryngoscopy attempt should also be considered a performance error.
Our complete study reviews each performance error in further detail and even addresses recommendations on how to mitigate them, but we submit here simply to introduce readers to the concept that performance errors are perhaps what we should truly be tracking and training to avoid. To our knowledge, our data will be the first to not only identify the performance errors but also attempt to establish the frequency and prevalence of each. These technical goals should be part of the feedback given to residents, both in real time and afterwards during review. This taxonomy creates the language and highlights the organization of the performance errors that we found. It is our hope that attendings responsible for supervising emergency intubations will be encouraged to utilize recorded video laryngoscopy attempts with this taxonomy to provide structured education and feedback to residents. ABOUT THE AUTHORS
Dr. Barnicle works at Yale University School of Medicine in the department of emergency medicine where he serves as one of the assistant residency program directors.
Dr. Bracey works at Albany Medical Center and is a member of the critical care consult service in the department of emergency medicine. He is an assistant residency program director and is the fellowship director of the inaugural class of the Resuscitation and Emergency Critical Care Fellowship beginning August 2022. Dr. Weingart is a dual boarded emergency department/surgical critical care physician, having completed his fellowships in trauma, surgical critical care, and extracorporeal membrane oxygenation at Shock Trauma Center in Baltimore, Maryland. He is faculty at Nassau University Medical Center. Dr. Weingart is best known for his podcast on resuscitation and ED critical care called EMCrit.
