The Science Journal of the American Association for Respiratory Care
At our medical center we successfully implemented a two-tiered response for emergency airway management by respiratory therapists and anesthesiologists. As part of the program, yearly recertification to maintain the skill is required. Following the first year of the program, each therapist was asked to return to the operating room (OR) and demonstrate competency in airway management. In order to optimize the recertification process, we conducted a prospective study at the end of the first year of the program to determine which variables correlated with the intubation success rate during the recertification period. The therapists (N=12) took a 21-question written test prior to return to the OR for skills assessment and anesthesia supervised intubation. The test included questions about pre-intubation assessment, anatomy, appropriate use of laryngoscope blades and the step-by-step process of the procedure. Following written testing, each therapist performed a series of intubations. At each attempt, one of two RT supervisors assessed whether the following elements of the procedure were performed correctly: airway assessment, equipment check, mask ventilation, laryngoscope placement (patient mouth opening and tongue displacement), blade pulled rather than levered on the teeth, and tube placement with the tip of the tube coming in from the right side. The frequency of the correct task performance and the first pass success rate was noted. Therapists were recertified by the anesthesiologist when all of the elements on the checklist were routinely performed, although a minimum of five was required of all therapists.
1. There was no correlation between the number of emergency intubations performed during the prior year by the therapist and the number of intubations required to be recertified.
2. There was a negative correlation (r=-0.8)(p<0.05) between a score on the written test and the number of intubations required for recertification (better test scores required fewer intubations).
3. Successful intubation on the first attempt occurred more frequently when all elements of the procedure were performed correctly (67% vs 36%, p<0.01).
4. The most common errors were not attempting to insert the tube from the right side of the mouth (27%) and levering the blade on upper teeth (13%). When the blade was levered, 80% of first attempts at intubation failed.
A good knowledge of the anatomy and procedure (as demonstrated on a written exam) is an important predictor of successful first pass intubations and overall competency in the airway management. Emphasis on teaching the proper use of the laryngoscope blade and insertion of the endotracheal tube from the right side of the mouth may be useful since this improves first attempt success rate. The number of emergency intubations in the preceding year is not a good predictor of skill maintenance, presumably because bad habits are not always corrected.