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How do paramedics learn and maintain the skill of tracheal intubation? A rapid evidence review

How do paramedics learn and maintain the skill of tracheal intubation? A rapid evidence review Introduction: Endotracheal intubation has been considered a core skill for all paramedics since the inception of the profession in the 1970s, and continues to be taught within the majority of pre-registration paramedic training programmes. However, the standards of both training and assessment of competence in intubation vary considerably between institutions; this has been compounded by reduced opportunities for supervised clinical practice within the operating theatre environment. The College of Paramedics’ Airway Working Group commissioned a rapid evidence review, to inform a consensus statement on paramedic intubation, with the research question: How do paramedics learn and maintain the skill of tracheal intubation? Methods: Rapid evidence reviews are literature reviews that use methods to accelerate or streamline the traditional systematic review process. Randomised controlled trials, quasi-randomised con- trolled trials, prospective and retrospective observational studies, systematic reviews and qualitative studies, published from 1970 onwards, were all eligible for inclusion. The search was restricted to paramedics/paramedic students and learning/maintaining the skill of tracheal intubation. Results: A comprehensive search of CINAHL, MEDLINE and Google Scholar was undertaken. Ten papers were classed as sufficiently relevant for inclusion. They identified that there is no clear definition of a paramedic having ‘learnt’ the skill of intubation. Suggested measures include first-pass success of 90% for pre-hospital intubation, or a range of measures, such as intubation success and complication rates, laryngoscopy technique and decision-making. Intubation training should use a range of modalities, including didactic lectures, videos and practical sessions on multiple types of airway manikins. Supervision by experienced faculty is required. Little is known about how paramedics maintain their skill in intubation, given the lack of clinical opportunity. Yearly skills retraining can help, and can be enhanced by demonstrations/lectures from experienced faculty. Conclusion: Further research is needed to understand how paramedics maintain their skill in intubation, given the limited opportunities to use the skill in a clinical setting and lack of opportunities with UK ambulance services for retraining. Keywords intubation; paramedic; skill acquisition; skill retention * Corresponding author: Richard Pilbery, Yorkshire Ambulance Service NHS Trust, Springhill, Brindley Way, 41 Business Park, Wakefield WF2 0XQ, UK. Email: r.pilbery@nhs.net Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 7 Published by Class Professional Publishing: www.classprofessional.co.uk 8 British Paramedic Journal 3(2) in compressed timeframes when compared to a systematic Background review. Endotracheal intubation (ETI) has been considered a core skill for all paramedics since the inception of the Inclusion and exclusion criteria profession in the 1970s, and continues to be taught within the majority of pre-registration paramedic training pro- In order to identify relevant studies that address the research grammes. In recent years, the practice of intubation by question, the PIOS (participants, interventions, outcomes, paramedics has been widely debated and its continued studies) acronym was used (Table 1). Readers familiar with use questioned. The increasing availability of supraglottic PICOS will note the omission of the ‘C’ for comparator. This parameter was not relevant to the research question in airway devices, guidance from the Joint Royal Colleges this RER and so was not included. Ambulance Liaison Committee and Resuscitation Council shifting the emphasis to the primary use of such devices rather than intubation in most patients, and limiting the Participants opportunity for paramedics to intubate in clinical practice The search was restricted to paramedics and/or paramedic have all contributed to the debate (Younger, Pilbery, & students in an attempt to ensure that the participants were Lethbridge, 2016). as homogeneous as possible. It is accepted that there The transition from vocational Institute of Health and are variations in the advanced airway management of Care Development national paramedic training to pre- paramedics from different countries and, in this search, registration programmes delivered within Higher Education potentially across the decades. However, it is assumed for Institutions has resulted in the standards of both training this review that paramedics by this definition are a more and assessment of competence in intubation varying con- homogeneous group than if nurse anaesthetists or doctors siderably between institutions; this has been compounded had been included. by reduced opportunities for supervised clinical practice within the operating theatre environment. Interventions This was restricted to tracheal intubation, although the Research question method of intubation (e.g. direct or video laryngoscopy) This rapid evidence review (RER) aimed to inform the was not restricted in the search. However, studies that College of Paramedics’ Airway Working Group as they only addressed whether direct or video laryngoscopy revise the previous consensus statement on paramedic was the best method of intubation, for example, were not intubation (College of Paramedics, 2008). The research eligible. No comparator was specified for this review. question of this RER was: How do paramedics learn and maintain the skill of tracheal intubation? Outcomes This review focused on the acquisition and maintenance Objectives of the skill of intubation, so studies that purely aimed The objectives of the RER are to: Table 1. Summary of inclusion and exclusion criteria. • evaluate literature from 1970 (the approximate time that the role of ‘paramedic’ first came into PIOS Inclusion criteria Exclusion criteria existence) to the present that examines how Participants Paramedics* and/or Other allied health- paramedics learn the skill of intubation and how student paramedics professionals, competence in the skill is maintained; and nurses and • present the findings from the review to assist the doctors Airway Working Group in developing and pub- Interventions Tracheal intubation Other airway lishing a revised consensus relating to paramedic management intubation. techniques Outcomes Learning and Morbidity/mortality maintenance of skill benefit of skill Methods Studies Randomised Editorials, position controlled trials, statements, Rapid evidence reviews quasi-randomised letters, literature controlled trials, reviews, case Due to constraints on cost and time, a systematic review prospective and reports and could not be undertaken. Instead, an RER based on the retrospective consensus methodology outlined by Collins, Coughlin, Miller, and observational studies, statements Kirk (2016) was utilised. RERs (also referred to as rapid systematic reviews evidence assessments or rapid reviews) are literature and qualitative studies reviews that use methods to accelerate or streamline the *Studies including paramedics and other healthcare professionals traditional systematic review process (Ganann, Ciliska, could be included if paramedic data could be separated. & Thomas, 2010). As such, they are typically completed Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 9 to address questions about whether paramedics should appraisal score of 1–3 was awarded, based on the most intubate or not were not eligible for inclusion. commonly awarded score for each criterion. Only papers that scored more than 1 for relevancy and 1 for robustness were included in the final review synthesis. Studies Randomised controlled trials (RCTs), quasi-randomised Data synthesis controlled trials, prospective and retrospective observa- tional studies, systematic reviews and qualitative studies, Once the final papers for inclusion in the RER had published from 1970 onwards, were all eligible for inclu- been selected, a narrative synthesis of the evidence was conducted. This consisted of: sion. There was no restriction on language, but results were limited to research on humans. Editorials, position 1. describing the volume and characteristics of the statements, letters, non-systematic literature reviews, case evidence base; reports and consensus statements were not eligible. 2. utilising the synthesis to answer the research questions; 3. highlighting the implications of the findings; Search strategy and Both CINAHL and MEDLINE were used for the literature 4. making recommendations for further research. search, with grey literature searched via Google Scholar (the first 100 results from this search were included). Results In addition, subject-matter experts from the College of Paramedics’ Airway Working Group were consulted about Based on the search strategy, 939 results were returned relevant papers they were aware of. An initial scoping from the CINAHL/MEDLINE search and the first 100 search to identify appropriate keywords and MESH head- results from the Google Scholar search were included. ings was undertaken by librarians at the University of Following removal of duplicates, 1009 records remained Hertfordshire. The final CINAHL/MEDLINE literature for ‘first-pass’ screening (review of title and abstract). search query and Google Scholar search were run on ‘Second-pass’ screening (review of full-text) was under- 23 December 2017. Full details of both can be found in taken for 77, which also identified a further eight papers. Supplementary 1. The full-text was retrieved for these papers and they were included in the ‘second-pass’ screening process. Seventeen passed the second-pass screening, with 10 being classed Study selection as sufficiently relevant and robust to be included in this A ‘first-pass’ of the search results was conducted by a single review (Figure 1). The complete list of first- and second- individual (RP) who screened the title and abstract against pass papers, including reason(s) for exclusion, can be the inclusion/exclusion criteria to determine whether it found in Supplementary 2. Second-pass papers which might be suitable for inclusion. Once this was completed, were not sufficiently robust or relevant can be found in the full-texts of papers that had made it through the first- Supplementary 3. pass process were obtained and reviewed (‘second-pass’). Those that met the inclusion criteria were put forward for Description of included studies inclusion in the review. In addition, the references sections of the full-text papers which were excluded at the second- The final 10 studies included in this review consist of eight pass stage were screened for potentially relevant studies to papers that examine how paramedics acquire the skill inform the review. of intubation, one paper that addressed intubation skill maintenance by paramedics and one study that attempted to address both. Papers came from several countries: Critical appraisal six from the United States, and one each from the UK, Papers that successfully made it past the second-pass Canada, Australia and Japan. Publication dates for papers process were critically appraised in two stages. The first varied, with six published 10–20 years ago and four pub- stage of the critical appraisal phase was to determine the lished within the last 10 years. Critical appraisal scores relevancy of the paper in relation to the RER research were fairly evenly split, with five papers scoring two, and question. A score of 1–3 was awarded for relevancy based five scoring three. All included papers scored a two for on the population, intervention and outcome of the study, relevancy. with 1 indicating low relevancy and 3 high. Most papers (seven) were interventional in design, with The robustness of the evidence was determined by two of these being RCTs. The remainder were observ- evaluating each paper against a list of criteria. Separate ational. Studies that examined intubation attempts by lists of criteria were utilised for quantitative interventional paramedics as an outcome included a mixture of live and observational studies, qualitative studies and system- intubation assessments, either in an operating theatre atic reviews. Each criterion was given a score of 1–3 setting or, in some cases, out-of-hospital, and manikin-only (1 being the lowest), and from these an overall critical assessments. A summary of study participants, outcomes Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 10 British Paramedic Journal 3(2) Figure 1. PRISMA diagram of literature search. and results can be seen in Table 2. The critical appraisals and 10 hours manikin training), were randomised into of each of the second-pass papers can be found in either a simulation-only group or traditional operating Supplementary 4. theatre placements. Students in the simulation-only group were subjected to a standardised curriculum including instruction of each basic step of intubation and repetition Pre-hospital advanced airway of the technique with various airways and case scenarios. management by ambulance technicians The average student completed 50 intubations on the sim- and paramedics: is clinical practice ulator with a range of 40–70, depending on each student’s sufficient to maintain skills? proficiency. A specific number of intubations was not This paper by Deakin, King, and Thompson (2009) required during simulator training; rather, students were consisted of a retrospective patient report form (PRF) required to achieve excellent technique with advancing review and a prospective telephone survey of UK levels of airway difficulty. Difficult airways were achieved ambulance service training schools. This was undertaken by using cervical spine immobilisation and using the sim- with the aim of assessing current airway practice, in order ulator options of tongue swelling, oropharyngeal swelling to review whether the initial training and maintenance of and laryngospasm. Students in the operating theatre airway skills provided an acceptable level of competence. (control) group underwent the local standard of obtaining The PRF review was conducted in a single ambulance 15 intubation attempts in theatres, under the supervision service, and the telephone survey included 15 ambulance of an anaesthetist. services in the UK, which is likely to be all of the services Both groups were subsequently tested by attempting at the time of the study. 15 intubations on patients in operating theatres as part of the study assessment. There were no formal patient inclusion/ exclusion criteria specified. Patients were selected on a Human patient simulation is effective non-consecutive basis at the discretion of the anaesthetist. for teaching paramedic students The primary analysis (to determine overall intubation endotracheal intubation success and first attempt success rates) was performed Hall et al. (2005) set out to test their hypothesis that using a generalised estimating equation (GEE) to account simulator training was as effective as using live patients for the cluster structure in the design arising from the for teaching paramedic students to intubate. The study repeat assessments for each student. Demographic vari- was an RCT involving 36 second-year paramedic students ables were compared using unpaired t-tests, chi-square from a single training college in Canada who, following tests and Fisher’s exact tests, depending on the nature of their standard airway training (20 hours didactic and video the demographic variables. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 11 Students typically had up to 17 intubation attempts Limited opportunities for paramedic during the session on a range of airway trainers (although, student endotracheal intubation training based on Owen and Plummer (2002), not all students were in the operating room able to practise on all trainers). Johnston, Seitz, and Wang (2006) conducted a survey of 161 programme directors of accredited training pro- Learning curve for paramedic endotracheal grammes in the United States. They sought to ‘characterise intubation and complications the nature of the operating theatre training provided to paramedic students for learning tracheal intubation’. An The objective of Toda, Toda, and Arakawa’s (2013) study anonymous closed-question survey was sent out, although was to assess the efficacy of the intubation training free-text comments were encouraged. Analysis was programme for paramedics by addressing two questions: limited to descriptive statistics (medians and interquartile 1) How much does the success rate of tracheal intubation ranges (IQRs)). A total of 192 programme directors were improve over the course of the 30 live intubation attempts? contacted and 161 completed surveys were returned, a 2) How much does the frequency of complications possi- response rate of 85%. bly associated with intubation decrease? A total of 32 para- medics (with no previous intubation experience on live patients) were trained in tracheal intubation between Training with video imaging improves the January 2005 and December 2011. All trainees received initial intubation success rates of paramedic instruction in the theoretical aspects of intubation through trainees in an operating room setting attending a standardised lecture, watching a video and Levitan, Goldman, Bryan, Shofer, and Herlich (2001) then practising on a manikin. Study participants intubated undertook a study to test the hypothesis that training with patients chosen by their supervising anaesthetist and were the use of videos of laryngoscopy from the point of view allowed two attempts per patient. The anaesthetist recorded of the person using the laryngoscope, in addition to tradi- the number of attempts and any complications possibly tional didactic and manikin instruction, would improve associated with the intubation, including: hoarseness, sore success rates of paramedic students when intubating throat, lip laceration, oral bleeding, gingival bleeding, lip in operating theatres. In the intervention (video) group, bleeding, pharyngeal bleeding, tongue laceration, dental students viewed a 26-minute video showing 15 laryngo- damage, lip swelling and tongue bleeding. scopies. Each student had to watch the video three times The authors constructed a generalised logistic regression prior to commencing their operating theatre placement, model to determine the probability of success, including in addition to the standard 42 hours of classroom instruc- variables of initial and final success rates, learning speed tion, consisting of didactic teaching and manikin practice and number of intubation attempts at which the success rate that students traditionally undertook. Note that there improved the most. A similar model was constructed for were no specified inclusion/exclusion criteria. In total, the probability of complications. 149 students provided data on 805 intubation attempts in operating theatres. Defining the learning curve for paramedic student endotracheal intubation Learning endotracheal intubation Wang, Seitz, Hostler, and Yealy (2005) sought to deter- in a clinical skills learning center: mine whether paramedic student intubation success is a quantitative study associated with accumulated live intubation experience, Plummer and Owen (2001) based their study on the adjusted for elapsed time since first intubation attempt hypothesis that the process of learning to intubate airway and the clinical setting (i.e. operating theatre, emergency trainers (manikins) may be subjected to quantitative department, intensive care, other in-hospital or out-of- analysis, and that such analysis would provide insight into hospital). Data for the study were obtained from the how instruction could be further improved. A total of 115 clinical and procedural experience tracker, Fisdap, which students, in groups of 2–4, took part in a training session at the time of the study was used by 175 paramedic pro- in a clinical simulation unit. Each session lasted 75–90 grammes throughout North America. Students elected to minutes and consisted of: allow the sharing of their anonymised data for research 1. an intubation video; purposes. 2. equipment familiarisation; Fixed-effects logistic regression was performed to 3. a demonstration; model the learning curve for intubation while adjusting 4. student attempts on an ‘easy’ simulator; for multiple relevant covariates and to account for per- 5. feedback on technique; paramedic student clustering effects. Intubation success 6. repeat attempts with feedback until consistent was modelled as the primary binary outcome. The key performance; independent variable was cumulative number of intubation 7. exposure to different/difficult simulators/intro- attempts. In addition, adjustments were made for clinical ducing alternative techniques and intubation aids. setting and elapsed days since first intubation attempt. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 12 British Paramedic Journal 3(2) Paramedic training for proficient pre- The effect of cross-training with adjustable airway model anatomies on laryngoscopy hospital endotracheal intubation skill transfer Warner et al. (2010) hypothesised that the number of Wong et al. (2011) tested the hypothesis that practising intubation attempts by paramedic students early in their intubation on a model in multiple configurations would training would be associated with a greater intubation enhance a student’s ability to transfer learned technical success rate prior to graduation. They performed a retro- skills to laryngoscopy on a new model. Medical and para- spective, observational analysis of intubation attempt data medic students with minimal previous laryngoscopy expe- collected as part of a training programme for Seattle Fire rience trained on one of three models: a novel adjustable Department paramedic trainees. manikin in multiple configurations, the same model main- Students in this programme undertake a nine-month tained in a single anatomical position or a commercial non- training programme and receive 2200 hours of training adjustable manikin. divided between 400 hours of lectures, 100 hours of labo- Students attended a 15-minute didactic session that ratory work, 600 hours of hands-on clinical work, 800 reviewed airway anatomy, discussed general principles hours of field internship and 300 hours of formal evalua- of airway management and explained the procedure for tion. Exposure to intubation begins with intensive manikin intubation. They watched a short film illustrating intu- training supervised by paramedic instructors and coincides bation and observed a demonstration of the procedure with lectures on airway management and skill laboratories. on a manikin. Following this, students were sequentially Students receive practical clinical experience in operating allocated to one of the three experimental groups. The theatres where they are taught airway assessment, bag- Laerdal group practised with the Laerdal adult intubation mask ventilation, direct laryngoscopy and rescue tech- model. The static group used the novel laryngoscopy sim- niques by anaesthetists. After completing a minimum of ulator maintained in the standard configuration (normal five successful intubations in adults in theatres, students face and jaw length, normal dentition and normal head are allowed to perform airway management in the field and spine range of motion). The variable group practised under the direct supervision of senior paramedics, but con- on the laryngoscopy simulator, changing the anatomy after tinue to acquire additional airway management experience every five intubation attempts. The first configuration was in the operating room. standard except that the teeth were removed. Subsequent Pre-hospital airway management experience extends for changes were to replace the teeth, lengthen the face to approximately eight months. Students may attempt intuba- 0.5 cm more than normal, shorten the mandible by 0.5 cm tion in the emergency department with permission and and finally increase the tension on the mandible slider direct supervision from attending physicians. Additional to adjust the position of the mandible in relation to the education in paediatric airway management is provided in skeletal base. theatres of Seattle Children’s Hospital under direction Regardless of group, each subject attempted laryngos- of faculty from the University of Washington School of copy with a Macintosh size 3 laryngoscope and intubation Medicine Department and Anaesthesiology. Advanced with a styletted 7.0 endotracheal tube, 25 times. An inves- training in surgical airway management is provided by tigator observed and scored the result of every attempt as the Director of Paramedic Training and the University success or failure. After training on the group-specific of Washington Department of Surgery in simulation manikin, all students attempted to intubate the adjustable laboratories. model with the mouth opening reduced from 5 cm to The data for analysis were collected as part of the 3.5 cm, a new configuration for all subjects. In addition, quality assurance process for the paramedic training. participants performed laryngoscopy with a different Data on each student’s intubation attempt were described airway manikin that none had seen, a Medical Plastics using measures of central tendency for continuous Airway model. Five attempts were recorded on each of the data and percentages for categorical data. Multi-variable two evaluation models. Success or failure for each attempt logistic regression, using GEEs with robust variance was assessed as in the training period. estimators, was used to assess the effect of cumulative The authors conducted the analysis by constructing experience on paramedic student pre-hospital intubation a mixed linear model to take account of the hierarchical success rates while adjusting for confounding variables. structure of the design; multiple measurements at different Cervical spine precautions in trauma, cardiac arrest and occasions were nested within each subject. rapid-sequence induction were considered as potential confounders in the analysis. The relationship between Paramedic self-efficacy and skill retention pre-hospital intubation success rate and total number of in pediatric airway management intubation attempts was summarised by plotting the pre- dicted success rate and 95% prediction intervals from the The aim of the study by Youngquist et al. (2008) was to regression equation as a function of cumulative number evaluate the effect of paediatric airway management of intubation attempts. training and periodic retraining on the self-efficacy and Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 13 skill performance of paramedics. They hypothesised that 1. How do paramedics learn the skill of intubation? an increase in both self-efficacy and skill performance 2. How do paramedics maintain the skill of would occur with both training and retraining and that intubation? the nature of the retraining programme would have a In order to answer these questions, it is first necessary statistically significant influence on both self-efficacy and to define when a paramedic is considered to have ‘learnt’ skill performance. the skill of intubation. Although all papers described This was a prospective, unblinded trial comparing various methods of learning intubation, including didactic three alternative retraining methods for paediatric airway lectures, manikin practice and live patient experience, management with a bag-valve-mask (BVM) and tracheal such as in operating theatres, emergency departments intubation. A convenience sample of 245 paramedics or out-of-hospital, few acknowledge that a definition of drawn from the Paediatric Airway Management Project, having learnt to intubate is not clearly defined. a paediatric airway management skills course that trained 2520 paramedics from two US EMS services, made up the participants for the study. They were allocated to one of Defining intubation skill proficiency/ four retraining groups: competency 1. No retraining (control group). Proficiency and competency were used interchangeably 2. A videotape demonstrating BVM and intubation within several studies in this review, and authors did not skills (the same training tape used to supplement always clearly define the terms, but all made an associa- initial training (videotape group)). tion with intubation success rates and/or complication 3. A self-directed learning method, in which para- rates as measures of becoming proficient/competent at medics were given instructional materials regard- intubation. Deakin et al. (2009) acknowledged that it was ing BVM and intubation skills. Paramedics were difficult to define the meaning of the word competent encouraged to practise skills in teams, using in relation to intubation, but intimated that intubation provided manikins and equipment (self-directed success is a measure of this. Wang et al. (2005) went group). 4. A lecture and demonstration by two instructors in further, stating that the number of intubation attempts addition to instructor-facilitated practice (lecture/ does not demonstrate the quality of performance. While demonstration group). they did define intubation proficiency in terms of the number of successful intubations, they also highlighted Subjects were asked to complete a 24-question self- that avoidance of technical errors, students’ laryngoscopy efficacy questionnaire both before and immediately after technique and sound decision-making should also be in initial training in paediatric airway management (and the mix, although admitted that this blend has not been prior to testing), and again before and after the retraining defined. Warner et al. (2010) specifically examined first session. Following completion of all questionnaires, para- attempt success at intubation as their primary outcome medics underwent paediatric airway management skills variable as they felt this was also a measure of minimising testing with the use of BVM and paediatric intubation on potential patient complications. a manikin. Performance was rated as fail, pass, high pass or honours for each skill. Both training and retraining If intubation success rates (either overall or first were performed by the same two research nurses, who also attempt) and complication rates are to be included in a scored paramedics on skills testing based on a written list definition of having successfully learnt the skill of intuba- of skill components. Passing required at least 70% comple- tion, then the acceptable percentage of both these rates tion of these skill components, high pass required at needs to be decided. Warner et al. (2010) defined a pre- least 80% and honours was awarded to those successfully hospital intubation success rate of 90% as an appropriate completing at least 90% of the skill components. target for the paramedic students in their study, and this Chi-square and Fisher’s exact tests were performed figure appeared in two other studies, although this was not to compare categorical variables. Generalised linear explicitly endorsed as a desirable target (Toda et al., 2013; models and t-tests were used to test differences in means Wang et al., 2005). of normally distributed continuous variables. Kruskal- Only Toda et al. (2013) provided any data about compli- Wallis tests were used to test for differences in location cations rates and these arguably have limited applicability between non-normally distributed continuous variables. since not all of them could be attributable to the intubation Finally, an ordinal logistic regression model was created attempt. In anaesthetised patients in the operating theatre, to describe the effects of the retraining method on scores they reported a complication rate of 53% decreasing obtained in airway skills testing. to 31% during the 30 intubation attempts the paramedic students made. The vast majority of complications were Discussion minor, either hoarseness or a sore throat, which are not likely to be of great concern to patients eligible for pre- The two key review questions that this RER aimed to hospital intubation. answer were: Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Table 2. Summary of study participants, outcomes and results. Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country 2 2 Survey undertaken Deakin et al. Retrospective, 269 paramedics with a PRF review: intubation success 128/269 paramedics (47.6%) had undertaken no intubation and 204 (75.8%) had undertaken one during transition to (2009) observational documented intubation rate, intubations per paramedic intubation or fewer in the 12-month study period. higher education. (PRF, review) attempt. Median number per annum, intubation attempts. May 2008 First-pass success occurred in 320/394 (81.2%) of Most likely historic of intubations during study LMA insertion also included. Prospective, UK attempts (no data recorded in 45 PRFs). picture of previous, period is 1 (range 0–11). observational Survey: LMA use by technicians/ vocational-style 15 ambulance services responded to survey. 13 (survey) 15 UK ambulance services paramedics, initial and ongoing requirements required intubations to be performed in theatre. 10 responded to survey. training for intubation and required 25 intubations, 2 required 20 (one of these LMA. had a caveat that this was acceptable if assessed as competent), 1 required 13 (if competent), 1 required 10, 1 required 5. For ongoing training, 3 services conducted annual manikin assessment, 2 conducted a mannikin assessment every 2 years and 1 sent paramedics to spend 1 day in theatre if number of intubations deemed inadequate. Hall et al. (2005) Prospective, 36 second-year paramedic Overall intubation success rate. Overall success rate 87.8% in SIM-only group and 84.8% 3 2 N/A interventional students with no prior in the OT group. First attempt success rate 84.4% May–Dec 2003 Intubation success, first attempt (RCT) intubation training or and 80% (SIM and OT groups respectively). Neither success, complications incl. Canada experience. statistically significant. dental trauma, airway bleeding, 540 patients (270 in each oxygen desaturation <85%, 11/18 students in the SIM group ≥ 13 successful group), mean age 43.0 years arrhythmias, oesophageal intubations. (range 3–88 years) in the intubation. 12/18 students in the OT group ≥ 12 successful SIM group and 44.1 years intubations. (range 15–87 years) in the The mean time to successful intubation was 47.2 OT group (p = 0.48). 12 seconds in the SIM group and 43.0 in the OT group, patients under 18 years in with a difference of 4.2 (95% CI = −0.5 to 8.8). the SIM group and 7 in the OT group (p = 0.24). The Skill acquisition during the process of testing did not study groups were well occur in either group, because the overall success matched for predictors of rates were consistent throughout the 15 test airway difficulty including: intubations. BMI, dentures, Mallampati Test intubations were interrupted for patient safety scores, thyromental distance, in 13 of 540 test intubations (2.4%). 8 of 270 test paralytic use and overall intubations (2.9%) in the SIM group and 5 of 270 airway difficulty. (1.9%) in the OT group were interrupted (p = 0.57). Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Reasons included airway difficulty (n = 5), ventricular arrhythmia during laryngoscopy (n = 1), anaesthetist unaware of study protocol (n = 1), student’s request (n = 1) and unspecified (n = 5). The mean time from training to testing was 7.5 weeks in the SIM group and 7.0 weeks in the OT group (p = 0.99). There was no difference between groups for the overall intubation success rate in students with longer delays between training and testing (p = 0.31) Johnston et al. Prospective, 161 programme directors Opportunity for intubation by Median time in theatres 17–32 hours. Half of 2 2 161/192 (85%) (2006) observational of CAAHEP accredited paramedic students. programmes provided < 16 hours per student. completed surveys paramedic training Median intubation attempts 6–10 per student. 58% returned June–Sept 2005 Average training hours per programmes. respondents reported increased competition for student. Average intubation USA operating theatre placements to practise intubation. attempts, student support, Increasing use of LMAs and medical-legal concerns graduate fulfilment of national highlighted in free text. recommendation of 5 intubations, access to operating Reduction in access identified by 52 programmes (32%) theatres over past 2–3 years. and 56 (35%) expected operating theatre placements to reduce in next 2–3 years. Levitan et al. Prospective, Paramedic students (no other Intubation success, number 113 students, comprising 4 years of paramedic classes 2 2 N/A (2001) interventional demographic data provided). of intubations per student. (1995–1998, i.e. control group), performed 783 (historic Differences between groups laryngoscope insertions. The mean intubation success 1995–1998 controls) in terms of participant age, rate was 46.7% (95% CI, 42.2–51.3%, SD ± 24.7%). USA gender and level of education. The range of laryngoscope insertions per student was 1–15 (mean 6.99, mode 6). In the video (intervention) group (paramedic classes 1998–1999), 36 students performed 102 laryngoscopies, with a mean individual success rate of 88.1% (95% CI, 79.6–96.5%, SD ± 25.9%). The range of insertions was 1–10 (mean 2.8, mode 3). Comparing the traditional group with the video group, the difference in success rates was statistically significant (P ≤ 0.0001; 46.7% vs. 88.1%, difference 41.4%, 95% CI, 31.1%–50.7%). The video and traditional groups did not differ in terms of age (25.0 vs. 26.1, P = 0.48), male sex (65.8% vs. 52.6%, P = 0.147) or level of education (87.5% grade 12 vs. 86.8% grade 12, P = 0.375). (continued) Table 2. (Continued) Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Plummer and Prospective, 115 students, mostly medical Models of intubation success. The rate of successful ETI increased from 6% on the 2 2 Owen and Plummer Owen (2001) interventional students (95), remainder first trial to approximately 80% after 15 trials. Trainees (2002) was critical care trainees and became familiar with an airway trainer after multiple not included 1 year, date student paramedics (13). trials, as demonstrated by a 50% decrease in the odds in this review not specified of successful ETI when starting on a new trainer. The (was primarily a (paper learning model indicated that a trainee learns about description of a new accepted May as much from 1 successful ETI as from 12 (95% CI, clinical simulation 2001) 2–23) failed trials. The log of the number of intubation unit). Did describe Australia attempts correlated with intubation success (OR 6.8, some data from this 95% CI, 4.3–11). Paramedic students were significantly study. Suggested better than medical students. Choice of instructor did paramedic students have a significant adverse effect on intubation success. approached 100% success after 6 attempts Toda et al. (2013) Prospective, 32 paramedics, no details on How much does the success 32 paramedics attempted 1049 intubations. 4 attempts 3 2 Unclear whether interventional selection. rate of tracheal intubation aborted. 1 due to no vocal cord visualisation, 1 due to skillset of Jan 2005–Dec by paramedics improve over tooth mobility and 2 because of dental damage during paramedics in Japan 2011 Patients: healthy surgical the course of the 30 live BVM ventilation. comparable with UK patients who required Japan experiences? intubation as part of their Only data for each trainee’s first 30 patients were used anaesthetic management and How much is the frequency to avoid survival bias, giving 960 observations for who were: aged 20 years or of complications possibly analysis. older, ASA physical status associated with tracheal Overall success rate increased from 71% to 87% (CI, class I or II and no evidence intubation decrease? 82–94%) after training on 30 patients. Used model of a potentially difficult to predict number of attempts required for 90% and airway. 95% success: 31.5 (95% CI, 27.6–54.3) and 38.6 (CI, 31.2–76.9). Complications all minor. Overall complication rate decreased from 53% to 31% after 30 patients. No significant learning up to 13 experiences with fastest learning period around 19 intubations. Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Wang et al. Retrospective, 891 students from 60 Relationship between intubation Mean number of intubations per student 9.5 (median 7, 2 2 N/A (2005) observational paramedics programmes in success and cumulative number IQR 4–12). Self-reported intubation success. Overall USA, 802 attempted a total of intubations. 87.5% (95% CI, 86.7–88.2), pre-hospital (n = 903) May 1999–Dec of 7635 ETIs. No ETIs were success 74.8% (71.9–77.6%). reported by 89 students. Learning curve for paramedics increased from 77.8% USA Only first 30 intubation to 95.8% over 30 ETI procedures. When stratified attempts included, leaving by clinical setting, suggests more than 30 intubations 7398 intubations for study required to achieve >90% success rate with pre- inclusion. No student or hospital intubations. patient demographics available. Warner et al. Retrospective, 56 paramedic students from Primary outcome successful 56 paramedic students in 3 consecutive classes 3 2 N/A (2010) observational Seattle Fire Department. placement of an ETT in completed training and were included in study. 1616 No other details. the trachea by the student, intubations attempted (median 29 intubations per 3 years, no start regardless of number of student), 706 intubations in operating theatres and date (paper attempts. 576 in pre-hospital setting. submitted Jan 2009) Secondary outcome. Pre-hospital intubation success 88% for all students, first-pass success 66%. USA First-pass success rates for student ETI attempts in the Odds of intubation success increased by 1.097 for each pre-hospital setting. successive patient (95% CI, 1.026–1.173). First-pass success OR 1.061 (1.014–1.109). Cumulative exposure to pre-hospital intubation most important factor in pre-hospital success. First-pass success of 90% requires more than 20 attempts. Wong et al. Prospective, 51 paramedic students in their Intubation success or failure and Overall 88% ± 1% success rate. first-pass success 3 2 N/A (2011) interventional second month of training and time to intubation. 65–70%. Success rate improved with number of 18 medical students, including attempts (OR 1.06, 95% CI, 1.03–1.08). Paramedic No study period 12 first-year, 3 second-year, students more likely to succeed than medical specified and 3 fourth-year students. students. Students trained on the novel trainer in a (paper static configuration were less likely to be successful accepted at intubating compared to the group using the Laerdal Aug 2010) airway trainer. USA A recent change in airway model reduced the odds of success to 70% of the odds without a change. However, practising laryngoscopy in a new airway model adjusted into 5 different configurations did not improve the odds of success over practising with only an airway trainer held in a fixed anatomy. (continued) Table 2. (Continued) Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Youngquist et al. Prospective, 245 paramedics, 184 male, Self-reported confidence and Paramedics from low-call-volume areas reported lower 3 2 N/A (2008) interventional median years as paramedic 8 anxiety performing BVM and baseline self-efficacy and derived larger increases (IQR 4–13), 141 paramedics ETI. Skills performance. with training, but also experienced the most decline 24 months, date were parents, total runs and between training events. Pass rates for BVM and ETI not specified Mean change between self- paediatric runs per 24hr were 66% (139⁄211) and 42% (88⁄212), respectively. (paper efficacy scores and skill reported, months since received April performance. Overall cohort self-efficacy was maintained over the elapsed training median 13 2008) study period. In ordinal regression modelling, only (IQR 7–16). Demographics the lecture and demonstration method was superior per group also included. to control, with an OR of achieving higher scores of 2.5 (95% CI = 1.2–5.2) for BVM and 5.2 (95% CI, 2.4–11.2) for intubation. Poor performance with intubation but not BVM was associated with time elapsed since training (p = 0.01). Self-efficacy ratings were not predictive of skill performance. ASA = American Society of Anesthesiologists; BMV = bag-valve-mask; CAAHEP = Commission on Accreditation of Allied Health Education Programmes; CAS = critical appraisal score; CI = confidence interval; ETI = endotracheal intubation; IQR = interquartile range; LMA = laryngeal mask airway; OR = odds ratio; OT = operating theatre; PRF = patient report form; RCT = randomised controlled trial; REL = relevance score; SIM = simulation. Pilbery 19 (Plummer & Owen, 2001; Wong et al., 2011); one exam- The learning curve for intubation ined the use of videos from the point of view of a laryngo- Three papers aimed to model the relationship between the scopist as part of the students’ training (Levitan et al., number of intubation attempts and intubation success 2001), and one aimed to determine whether training (Toda et al., 2013; Wang et al., 2005; Warner et al., 2010). intubations in the operating theatre could be replaced by Toda et al. (2013) examined 960 intubation attempts by training on a high-fidelity simulator (Hall et al., 2005). 32 Japanese paramedics. Having modelled the data, they Plummer and Owen (2001) used six different airway determined that 31.5 attempts were required for an overall trainers (one had two configurations, with and without 90% intubation success rate (i.e. all attempts, not just first) a cervical collar applied, making seven different airway with a 95% CI ranging from 27.6 to 54.3 attempts. In addi- trainers overall). They found that the students’ success tion, the relationship between probability of success and rate was the log of the number of intubation attempts, with the cumulative number of attempts was S-shaped, with a an initial steep learning curve that plateaued after approxi- plateau in intubation success rates for the first 13 attempts, mately 12 attempts. However, changing the airway trainer suggesting limited learning, before a sharp rise in success reduced the odds of a successful intubation by 50%. rates at around 19 intubation attempts. However, care Only 13 of the 100 students were paramedics and it needs to be taken when extrapolating models beyond the appeared that the instructor facilitating the event had an range of the data provided, and it is not clear how similar impact on intubation success. In addition, the allocation Japanese paramedics are to UK paramedic students. of airway trainer was not consistent, making these results Finally, all these intubations took place in the operating less reliable and applicable to paramedics. theatre and were chosen by the supervising anaesthetist, Wong et al. (2011) also tested multiple airway trainers. which might not reflect the challenges of pre-hospital Their motivation was in part due to the difficulty in obtain- intubation attempts. ing live patient experiences for non-anaesthetists as well This difference in location where the intubation was as recognising that training on a single model does not performed was incorporated into the analysis of the translate to good performance on different manikins (or Warner et al. (2010) and Wang et al. (2005) studies. Warner real patients). They developed a novel airway trainer with et al. (2010) found a significant, positive relationship adjustable anatomy. As with the Plummer and Owen between cumulative intubation attempts. In contrast to (2001) study, not all of the students were paramedics, Toda et al. (2013), overall success rates plateaued at around although most were (51 paramedic students and 18 medical 10–15 intubations, although the starting success rate in this students). On modelling the data, they too noticed a decline cohort was above 80%, compared to Toda et al.’s (2013) (although a more modest 30% reduction) in intubation paramedics with a success rate of around 70%. However, success when changing airway trainer. when only first attempt success was examined, intubation Levitan et al. (2001) introduced a video showing success rates started at around 60%, rising to approxi- 15 laryngoscopies from the point of view of the laryngo- mately 80% after 20 attempts, leading the authors to con- scopist, which, at the turn of the millennium, was proba- clude that more than 20 attempts would be required to bly very novel. However, these videos are now easy to obtain a first-attempt intubation success rate of 90%. find on social media, but nonetheless compared to the In contrast to the other two studies in this section, Wang control group, who only had simple line drawings and et al. (2005) conducted a retrospective review of Fisdap; manikin anatomy, this appeared to be an advantage when an internet-based system used to record paramedic student the students went to operating theatres to practise intuba- clinical and procedural experience. While not interven- tion. The mean success rate for the video group was 88.1% tional, it did allow the authors to extend their scope beyond (95% CI, 79.6–96.5%) compared to the control group a single centre. They included 7635 intubation attempts (no video) mean of 46.7% (95% CI, 42.2–51.3%). This from 802 paramedic students on 60 paramedic programmes study did use historic controls, so it is possible that other across North America. Like Warner et al. (2010), they strat- confounding factors have not been taken into account. ified their results in order to model intubation success rates Given the limited opportunities to gain intubation by location, and found a significant relationship between experience in operating theatres for paramedic students cumulative intubation attempts and probability of intubation (Deakin et al., 2009; Johnston et al., 2006) both in the UK success. Overall, intubation success rates increased from and the US, it is no surprise that a study has been con- 77.8% to 95.8% over 30 intubation attempts. However, ducted to see whether some of these intubation attempts when examining pre-hospital intubations, success rates on live patients could be replaced by high-fidelity simula- started at around 50%, rising to in excess of 85% after tion. Hall et al. (2005) conducted an RCT with a group of 30 attempts. They drew the conclusion that more than 42 paramedic students. Having completed the standard 15–25 live intubations, preferably in a range of settings, airway training curriculum consisting of 20 hours of were required to reach acceptable intubation success rates. didactic and video training, supplemented with 10 hours of practice on a manikin, students were randomised into Intubation training aids either receiving 10 hours of training on a high-fidelity Two papers in the review examined the use of different simulator (METIman) facilitated by an anaesthetist and manikin types as part of paramedic airway education senior emergency department doctor, or being in the Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 20 British Paramedic Journal 3(2) control group and going to theatres to perform 15 population, although this would have potentially made intubation attempts. Students in the intervention arm findings less relevant to paramedics. (simulation group) completed an ‘average’ of 50 intuba- tions on the simulator. Following this, both groups were Conclusion assessed in the operating theatre by performing 15 intuba- tion attempts. The first-attempt success rates were 84.4% In order to determine how paramedics learn and maintain and 80.0% in the simulation and control group, respec- the skill of intubation, a definition is required so it is clear tively, which was a non-significant difference. This led to what benchmark is to be used to state that a paramedic the conclusion that paramedic students could be trained on has ‘learnt’ the skill of intubation. This could be a single high-fidelity simulators as effectively as traditional live measure such as first-pass success of 90% for pre-hospital patient intubation when assessed in the operating theatre. intubation, for example, or a range of measures, such as While Hall et al. (2005) do acknowledge the cost of the intubation success and complication rates, laryngoscopy manikin as an issue, the possibility that the experience technique and decision-making. of the faculty also contributed to the performance of the The precise number of intubations required to become simulator group was not considered. proficient at intubation is not clear, but based on the evi- dence in the review, to achieve a first-pass intubation success rate of 90%, paramedic students require 25–30 Maintaining the skill of intubation intubations on live patients, preferably in a range of Compared to skill acquisition, there was a paucity of environments (e.g. commencing in operating theatres evidence that specifically addressed how paramedics or other in-hospital settings and then out-of-hospital). maintained proficiency/competence in the skill of intuba- Additional intubations are desirable, either with live tion. Two papers (Deakin et al., 2009; Youngquist et al., patients or on high-fidelity manikins. 2008) in the review addressed this issue, although Deakin Intubation training should use a range of modalities, et al. (2009) conducted a telephone survey of training including didactic lectures, videos and practical sessions schools in 2008, which is unlikely to provide more than on airway manikins. Students should not be trained on a historic view of the maintenance of advanced airway only a single manikin, but should have access to multiple skills. The study by Youngquist et al. (2008), however, did types. Supervision by experienced faculty is required. examine the performance of paramedics between two time Little is known about how paramedics maintain their points (a median of 13 months, IQR 7–16 for all groups). skill in intubation, given the lack of clinical opportunity. Although the study only considered intubation in children, Yearly skills retraining can help, and can be enhanced by there was a significant decline in skills performance as demonstrations/lectures from experienced faculty. time to retraining increased (odds ratio (OR) 0.93, 95% CI, Further research is needed to understand how para- 0.87–0.98). As an RCT evaluating different types of train- medics maintain their skill in intubation, given the limited ing modality (video only, self-directed learning or lecture opportunities to use the skill in a clinical setting and and demonstration by instructors followed by instructor- lack of opportunities with UK ambulance services for facilitated practice), the study also revealed that the only retraining. retraining intervention that had a significant increase in skills performance was the lecture/demonstration group Acknowledgements (OR 5.17, IQR 2.39–11.19). These results suggest that good quality retraining can help in improving skills perfor- Thanks to Professor Julia Williams from the College of mance (at least during an assessment on a paediatric Paramedics’ Airway Working Group for her assistance in manikin), especially in a patient group where clinical developing the protocol for this rapid evidence review. In exposure is likely to be limited. addition, the support from the librarian at the University of Hertfordshire, who provided some early guidance on potential search terms and MESH headings for the Limitations literature review, also deserves recognition. There are a number of important limitations with this review. The most significant is the methodology. Although Conflict of interest RERs do emulate aspects of a systematic review, they are not as comprehensive due to time and resource con- Richard Pilbery is the Editor of the British Paramedic straints. It is possible that relevant papers were not included Journal. in the review. In addition, the RER was conducted by a single person (RP), which may have resulted in papers Funding being excluded from the study inappropriately. Finally, given the limited data to inform the research question, it This report was commissioned and paid for by the College may have been prudent to have widened the eligible of Paramedics. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 21 in an operating room setting. Annals of Emergency References Medicine, 37, 46–50. College of Paramedics. (2008, September). College of Owen, H., & Plummer, J. L. (2002). Improving learning of a Paramedics (British Paramedic Association) updated clinical skill: The first year’s experience of teaching position paper following JRCALC recommendations on endotracheal intubation in a clinical simulation facility. paramedic intubation. Retrieved from https://www. Medical Education, 36, 635–642. collegeofparamedics.co.uk/downloads/College_of_ Plummer, J. L., & Owen, H. (2001). Learning endotracheal Paramedics_post_report_intubation_position_paper_ intubation in a clinical skills learning center: A V4.pdf. quantitative study. Anesthesia and Analgesia, 93, 656. Collins, A., Coughlin, D., Miller, J., & Kirk, S. (2016, October Toda, J., Toda, A. A., & Arakawa, J. (2013). Learning curve for 17). The production of quick scoping reviews and rapid paramedic endotracheal intubation and complications. evidence assessments. Retrieved from https://www.gov. International Journal of Emergency Medicine, 6, 1–8. uk/government/publications/the-production-of-quick- Wang, H. E., Seitz, S. R., Hostler, D., & Yealy, D. M. (2005). scoping-reviews-and-rapid-evidence-assessments. Defining the learning curve for paramedic student Deakin, C. D., King, P., & Thompson, F. (2009). Pre-hospital endotracheal intubation. Prehospital Emergency Care, 9, advanced airway management by ambulance technicians 156–162. and paramedics: Is clinical practice sufficient to maintain Warner, K. J., Carlbom, D., Cooke, C. R., Bulger, E. M., skills? Emergency Medicine Journal, 26, 888–891. Copass, M. K., & Sharar, S. R. (2010). Paramedic training Ganann, R., Ciliska, D., & Thomas, H. (2010). Expediting for proficient pre-hospital endotracheal intubation. systematic reviews: Methods and implications of rapid Prehospital Emergency Care, 14, 103–108. reviews. Implementation Science, 5, 56. Wong, W., Kedarisetty, S., Delson, N., Glaser, D., Moitoza, J., Hall, R. E., Plant, J. R., Bands, C. J., Wall, A. R., Kang, J., Davis, D. P., & Hastings, R. H. (2011). The effect of cross- & Hall, C. A. (2005). Human patient simulation is training with adjustable airway model anatomies on effective for teaching paramedic students endotracheal laryngoscopy skill transfer. Anesthesia and Analgesia, intubation. Academic Emergency Medicine, 12, 113, 862–868. 850–855. Younger, P., Pilbery, R., & Lethbridge, K. (2016). A survey of Johnston, B. D., Seitz, S. R., & Wang, H. E. (2006). Limited paramedic advanced airway practice in the UK. British opportunities for paramedic student endotracheal Paramedic Journal, 1, 9–22. intubation training in the operating room. Academic Youngquist, S. T., Henderson, D. P., Gausche-Hill, M., Emergency Medicine, 13, 1051–1055. Goodrich, S. M., Poore, P. D., & Lewis, R. J. (2008). Levitan, R. M., Goldman, T. S., Bryan, D. A., Shofer, F., & Paramedic self-efficacy and skill retention in pediatric Herlich, A. (2001). Training with video imaging improves airway management. Academic Emergency Medicine, the initial intubation success rates of paramedic trainees 15, 1295–1303. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png British Paramedic Journal Pubmed Central

How do paramedics learn and maintain the skill of tracheal intubation? A rapid evidence review

British Paramedic Journal , Volume 3 (2) – Sep 1, 2018

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Pubmed Central
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© 2018 The Author(s)
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1478-4726
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10.29045/14784726.2018.09.3.2.7
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Abstract

Introduction: Endotracheal intubation has been considered a core skill for all paramedics since the inception of the profession in the 1970s, and continues to be taught within the majority of pre-registration paramedic training programmes. However, the standards of both training and assessment of competence in intubation vary considerably between institutions; this has been compounded by reduced opportunities for supervised clinical practice within the operating theatre environment. The College of Paramedics’ Airway Working Group commissioned a rapid evidence review, to inform a consensus statement on paramedic intubation, with the research question: How do paramedics learn and maintain the skill of tracheal intubation? Methods: Rapid evidence reviews are literature reviews that use methods to accelerate or streamline the traditional systematic review process. Randomised controlled trials, quasi-randomised con- trolled trials, prospective and retrospective observational studies, systematic reviews and qualitative studies, published from 1970 onwards, were all eligible for inclusion. The search was restricted to paramedics/paramedic students and learning/maintaining the skill of tracheal intubation. Results: A comprehensive search of CINAHL, MEDLINE and Google Scholar was undertaken. Ten papers were classed as sufficiently relevant for inclusion. They identified that there is no clear definition of a paramedic having ‘learnt’ the skill of intubation. Suggested measures include first-pass success of 90% for pre-hospital intubation, or a range of measures, such as intubation success and complication rates, laryngoscopy technique and decision-making. Intubation training should use a range of modalities, including didactic lectures, videos and practical sessions on multiple types of airway manikins. Supervision by experienced faculty is required. Little is known about how paramedics maintain their skill in intubation, given the lack of clinical opportunity. Yearly skills retraining can help, and can be enhanced by demonstrations/lectures from experienced faculty. Conclusion: Further research is needed to understand how paramedics maintain their skill in intubation, given the limited opportunities to use the skill in a clinical setting and lack of opportunities with UK ambulance services for retraining. Keywords intubation; paramedic; skill acquisition; skill retention * Corresponding author: Richard Pilbery, Yorkshire Ambulance Service NHS Trust, Springhill, Brindley Way, 41 Business Park, Wakefield WF2 0XQ, UK. Email: r.pilbery@nhs.net Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 7 Published by Class Professional Publishing: www.classprofessional.co.uk 8 British Paramedic Journal 3(2) in compressed timeframes when compared to a systematic Background review. Endotracheal intubation (ETI) has been considered a core skill for all paramedics since the inception of the Inclusion and exclusion criteria profession in the 1970s, and continues to be taught within the majority of pre-registration paramedic training pro- In order to identify relevant studies that address the research grammes. In recent years, the practice of intubation by question, the PIOS (participants, interventions, outcomes, paramedics has been widely debated and its continued studies) acronym was used (Table 1). Readers familiar with use questioned. The increasing availability of supraglottic PICOS will note the omission of the ‘C’ for comparator. This parameter was not relevant to the research question in airway devices, guidance from the Joint Royal Colleges this RER and so was not included. Ambulance Liaison Committee and Resuscitation Council shifting the emphasis to the primary use of such devices rather than intubation in most patients, and limiting the Participants opportunity for paramedics to intubate in clinical practice The search was restricted to paramedics and/or paramedic have all contributed to the debate (Younger, Pilbery, & students in an attempt to ensure that the participants were Lethbridge, 2016). as homogeneous as possible. It is accepted that there The transition from vocational Institute of Health and are variations in the advanced airway management of Care Development national paramedic training to pre- paramedics from different countries and, in this search, registration programmes delivered within Higher Education potentially across the decades. However, it is assumed for Institutions has resulted in the standards of both training this review that paramedics by this definition are a more and assessment of competence in intubation varying con- homogeneous group than if nurse anaesthetists or doctors siderably between institutions; this has been compounded had been included. by reduced opportunities for supervised clinical practice within the operating theatre environment. Interventions This was restricted to tracheal intubation, although the Research question method of intubation (e.g. direct or video laryngoscopy) This rapid evidence review (RER) aimed to inform the was not restricted in the search. However, studies that College of Paramedics’ Airway Working Group as they only addressed whether direct or video laryngoscopy revise the previous consensus statement on paramedic was the best method of intubation, for example, were not intubation (College of Paramedics, 2008). The research eligible. No comparator was specified for this review. question of this RER was: How do paramedics learn and maintain the skill of tracheal intubation? Outcomes This review focused on the acquisition and maintenance Objectives of the skill of intubation, so studies that purely aimed The objectives of the RER are to: Table 1. Summary of inclusion and exclusion criteria. • evaluate literature from 1970 (the approximate time that the role of ‘paramedic’ first came into PIOS Inclusion criteria Exclusion criteria existence) to the present that examines how Participants Paramedics* and/or Other allied health- paramedics learn the skill of intubation and how student paramedics professionals, competence in the skill is maintained; and nurses and • present the findings from the review to assist the doctors Airway Working Group in developing and pub- Interventions Tracheal intubation Other airway lishing a revised consensus relating to paramedic management intubation. techniques Outcomes Learning and Morbidity/mortality maintenance of skill benefit of skill Methods Studies Randomised Editorials, position controlled trials, statements, Rapid evidence reviews quasi-randomised letters, literature controlled trials, reviews, case Due to constraints on cost and time, a systematic review prospective and reports and could not be undertaken. Instead, an RER based on the retrospective consensus methodology outlined by Collins, Coughlin, Miller, and observational studies, statements Kirk (2016) was utilised. RERs (also referred to as rapid systematic reviews evidence assessments or rapid reviews) are literature and qualitative studies reviews that use methods to accelerate or streamline the *Studies including paramedics and other healthcare professionals traditional systematic review process (Ganann, Ciliska, could be included if paramedic data could be separated. & Thomas, 2010). As such, they are typically completed Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 9 to address questions about whether paramedics should appraisal score of 1–3 was awarded, based on the most intubate or not were not eligible for inclusion. commonly awarded score for each criterion. Only papers that scored more than 1 for relevancy and 1 for robustness were included in the final review synthesis. Studies Randomised controlled trials (RCTs), quasi-randomised Data synthesis controlled trials, prospective and retrospective observa- tional studies, systematic reviews and qualitative studies, Once the final papers for inclusion in the RER had published from 1970 onwards, were all eligible for inclu- been selected, a narrative synthesis of the evidence was conducted. This consisted of: sion. There was no restriction on language, but results were limited to research on humans. Editorials, position 1. describing the volume and characteristics of the statements, letters, non-systematic literature reviews, case evidence base; reports and consensus statements were not eligible. 2. utilising the synthesis to answer the research questions; 3. highlighting the implications of the findings; Search strategy and Both CINAHL and MEDLINE were used for the literature 4. making recommendations for further research. search, with grey literature searched via Google Scholar (the first 100 results from this search were included). Results In addition, subject-matter experts from the College of Paramedics’ Airway Working Group were consulted about Based on the search strategy, 939 results were returned relevant papers they were aware of. An initial scoping from the CINAHL/MEDLINE search and the first 100 search to identify appropriate keywords and MESH head- results from the Google Scholar search were included. ings was undertaken by librarians at the University of Following removal of duplicates, 1009 records remained Hertfordshire. The final CINAHL/MEDLINE literature for ‘first-pass’ screening (review of title and abstract). search query and Google Scholar search were run on ‘Second-pass’ screening (review of full-text) was under- 23 December 2017. Full details of both can be found in taken for 77, which also identified a further eight papers. Supplementary 1. The full-text was retrieved for these papers and they were included in the ‘second-pass’ screening process. Seventeen passed the second-pass screening, with 10 being classed Study selection as sufficiently relevant and robust to be included in this A ‘first-pass’ of the search results was conducted by a single review (Figure 1). The complete list of first- and second- individual (RP) who screened the title and abstract against pass papers, including reason(s) for exclusion, can be the inclusion/exclusion criteria to determine whether it found in Supplementary 2. Second-pass papers which might be suitable for inclusion. Once this was completed, were not sufficiently robust or relevant can be found in the full-texts of papers that had made it through the first- Supplementary 3. pass process were obtained and reviewed (‘second-pass’). Those that met the inclusion criteria were put forward for Description of included studies inclusion in the review. In addition, the references sections of the full-text papers which were excluded at the second- The final 10 studies included in this review consist of eight pass stage were screened for potentially relevant studies to papers that examine how paramedics acquire the skill inform the review. of intubation, one paper that addressed intubation skill maintenance by paramedics and one study that attempted to address both. Papers came from several countries: Critical appraisal six from the United States, and one each from the UK, Papers that successfully made it past the second-pass Canada, Australia and Japan. Publication dates for papers process were critically appraised in two stages. The first varied, with six published 10–20 years ago and four pub- stage of the critical appraisal phase was to determine the lished within the last 10 years. Critical appraisal scores relevancy of the paper in relation to the RER research were fairly evenly split, with five papers scoring two, and question. A score of 1–3 was awarded for relevancy based five scoring three. All included papers scored a two for on the population, intervention and outcome of the study, relevancy. with 1 indicating low relevancy and 3 high. Most papers (seven) were interventional in design, with The robustness of the evidence was determined by two of these being RCTs. The remainder were observ- evaluating each paper against a list of criteria. Separate ational. Studies that examined intubation attempts by lists of criteria were utilised for quantitative interventional paramedics as an outcome included a mixture of live and observational studies, qualitative studies and system- intubation assessments, either in an operating theatre atic reviews. Each criterion was given a score of 1–3 setting or, in some cases, out-of-hospital, and manikin-only (1 being the lowest), and from these an overall critical assessments. A summary of study participants, outcomes Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 10 British Paramedic Journal 3(2) Figure 1. PRISMA diagram of literature search. and results can be seen in Table 2. The critical appraisals and 10 hours manikin training), were randomised into of each of the second-pass papers can be found in either a simulation-only group or traditional operating Supplementary 4. theatre placements. Students in the simulation-only group were subjected to a standardised curriculum including instruction of each basic step of intubation and repetition Pre-hospital advanced airway of the technique with various airways and case scenarios. management by ambulance technicians The average student completed 50 intubations on the sim- and paramedics: is clinical practice ulator with a range of 40–70, depending on each student’s sufficient to maintain skills? proficiency. A specific number of intubations was not This paper by Deakin, King, and Thompson (2009) required during simulator training; rather, students were consisted of a retrospective patient report form (PRF) required to achieve excellent technique with advancing review and a prospective telephone survey of UK levels of airway difficulty. Difficult airways were achieved ambulance service training schools. This was undertaken by using cervical spine immobilisation and using the sim- with the aim of assessing current airway practice, in order ulator options of tongue swelling, oropharyngeal swelling to review whether the initial training and maintenance of and laryngospasm. Students in the operating theatre airway skills provided an acceptable level of competence. (control) group underwent the local standard of obtaining The PRF review was conducted in a single ambulance 15 intubation attempts in theatres, under the supervision service, and the telephone survey included 15 ambulance of an anaesthetist. services in the UK, which is likely to be all of the services Both groups were subsequently tested by attempting at the time of the study. 15 intubations on patients in operating theatres as part of the study assessment. There were no formal patient inclusion/ exclusion criteria specified. Patients were selected on a Human patient simulation is effective non-consecutive basis at the discretion of the anaesthetist. for teaching paramedic students The primary analysis (to determine overall intubation endotracheal intubation success and first attempt success rates) was performed Hall et al. (2005) set out to test their hypothesis that using a generalised estimating equation (GEE) to account simulator training was as effective as using live patients for the cluster structure in the design arising from the for teaching paramedic students to intubate. The study repeat assessments for each student. Demographic vari- was an RCT involving 36 second-year paramedic students ables were compared using unpaired t-tests, chi-square from a single training college in Canada who, following tests and Fisher’s exact tests, depending on the nature of their standard airway training (20 hours didactic and video the demographic variables. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 11 Students typically had up to 17 intubation attempts Limited opportunities for paramedic during the session on a range of airway trainers (although, student endotracheal intubation training based on Owen and Plummer (2002), not all students were in the operating room able to practise on all trainers). Johnston, Seitz, and Wang (2006) conducted a survey of 161 programme directors of accredited training pro- Learning curve for paramedic endotracheal grammes in the United States. They sought to ‘characterise intubation and complications the nature of the operating theatre training provided to paramedic students for learning tracheal intubation’. An The objective of Toda, Toda, and Arakawa’s (2013) study anonymous closed-question survey was sent out, although was to assess the efficacy of the intubation training free-text comments were encouraged. Analysis was programme for paramedics by addressing two questions: limited to descriptive statistics (medians and interquartile 1) How much does the success rate of tracheal intubation ranges (IQRs)). A total of 192 programme directors were improve over the course of the 30 live intubation attempts? contacted and 161 completed surveys were returned, a 2) How much does the frequency of complications possi- response rate of 85%. bly associated with intubation decrease? A total of 32 para- medics (with no previous intubation experience on live patients) were trained in tracheal intubation between Training with video imaging improves the January 2005 and December 2011. All trainees received initial intubation success rates of paramedic instruction in the theoretical aspects of intubation through trainees in an operating room setting attending a standardised lecture, watching a video and Levitan, Goldman, Bryan, Shofer, and Herlich (2001) then practising on a manikin. Study participants intubated undertook a study to test the hypothesis that training with patients chosen by their supervising anaesthetist and were the use of videos of laryngoscopy from the point of view allowed two attempts per patient. The anaesthetist recorded of the person using the laryngoscope, in addition to tradi- the number of attempts and any complications possibly tional didactic and manikin instruction, would improve associated with the intubation, including: hoarseness, sore success rates of paramedic students when intubating throat, lip laceration, oral bleeding, gingival bleeding, lip in operating theatres. In the intervention (video) group, bleeding, pharyngeal bleeding, tongue laceration, dental students viewed a 26-minute video showing 15 laryngo- damage, lip swelling and tongue bleeding. scopies. Each student had to watch the video three times The authors constructed a generalised logistic regression prior to commencing their operating theatre placement, model to determine the probability of success, including in addition to the standard 42 hours of classroom instruc- variables of initial and final success rates, learning speed tion, consisting of didactic teaching and manikin practice and number of intubation attempts at which the success rate that students traditionally undertook. Note that there improved the most. A similar model was constructed for were no specified inclusion/exclusion criteria. In total, the probability of complications. 149 students provided data on 805 intubation attempts in operating theatres. Defining the learning curve for paramedic student endotracheal intubation Learning endotracheal intubation Wang, Seitz, Hostler, and Yealy (2005) sought to deter- in a clinical skills learning center: mine whether paramedic student intubation success is a quantitative study associated with accumulated live intubation experience, Plummer and Owen (2001) based their study on the adjusted for elapsed time since first intubation attempt hypothesis that the process of learning to intubate airway and the clinical setting (i.e. operating theatre, emergency trainers (manikins) may be subjected to quantitative department, intensive care, other in-hospital or out-of- analysis, and that such analysis would provide insight into hospital). Data for the study were obtained from the how instruction could be further improved. A total of 115 clinical and procedural experience tracker, Fisdap, which students, in groups of 2–4, took part in a training session at the time of the study was used by 175 paramedic pro- in a clinical simulation unit. Each session lasted 75–90 grammes throughout North America. Students elected to minutes and consisted of: allow the sharing of their anonymised data for research 1. an intubation video; purposes. 2. equipment familiarisation; Fixed-effects logistic regression was performed to 3. a demonstration; model the learning curve for intubation while adjusting 4. student attempts on an ‘easy’ simulator; for multiple relevant covariates and to account for per- 5. feedback on technique; paramedic student clustering effects. Intubation success 6. repeat attempts with feedback until consistent was modelled as the primary binary outcome. The key performance; independent variable was cumulative number of intubation 7. exposure to different/difficult simulators/intro- attempts. In addition, adjustments were made for clinical ducing alternative techniques and intubation aids. setting and elapsed days since first intubation attempt. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 12 British Paramedic Journal 3(2) Paramedic training for proficient pre- The effect of cross-training with adjustable airway model anatomies on laryngoscopy hospital endotracheal intubation skill transfer Warner et al. (2010) hypothesised that the number of Wong et al. (2011) tested the hypothesis that practising intubation attempts by paramedic students early in their intubation on a model in multiple configurations would training would be associated with a greater intubation enhance a student’s ability to transfer learned technical success rate prior to graduation. They performed a retro- skills to laryngoscopy on a new model. Medical and para- spective, observational analysis of intubation attempt data medic students with minimal previous laryngoscopy expe- collected as part of a training programme for Seattle Fire rience trained on one of three models: a novel adjustable Department paramedic trainees. manikin in multiple configurations, the same model main- Students in this programme undertake a nine-month tained in a single anatomical position or a commercial non- training programme and receive 2200 hours of training adjustable manikin. divided between 400 hours of lectures, 100 hours of labo- Students attended a 15-minute didactic session that ratory work, 600 hours of hands-on clinical work, 800 reviewed airway anatomy, discussed general principles hours of field internship and 300 hours of formal evalua- of airway management and explained the procedure for tion. Exposure to intubation begins with intensive manikin intubation. They watched a short film illustrating intu- training supervised by paramedic instructors and coincides bation and observed a demonstration of the procedure with lectures on airway management and skill laboratories. on a manikin. Following this, students were sequentially Students receive practical clinical experience in operating allocated to one of the three experimental groups. The theatres where they are taught airway assessment, bag- Laerdal group practised with the Laerdal adult intubation mask ventilation, direct laryngoscopy and rescue tech- model. The static group used the novel laryngoscopy sim- niques by anaesthetists. After completing a minimum of ulator maintained in the standard configuration (normal five successful intubations in adults in theatres, students face and jaw length, normal dentition and normal head are allowed to perform airway management in the field and spine range of motion). The variable group practised under the direct supervision of senior paramedics, but con- on the laryngoscopy simulator, changing the anatomy after tinue to acquire additional airway management experience every five intubation attempts. The first configuration was in the operating room. standard except that the teeth were removed. Subsequent Pre-hospital airway management experience extends for changes were to replace the teeth, lengthen the face to approximately eight months. Students may attempt intuba- 0.5 cm more than normal, shorten the mandible by 0.5 cm tion in the emergency department with permission and and finally increase the tension on the mandible slider direct supervision from attending physicians. Additional to adjust the position of the mandible in relation to the education in paediatric airway management is provided in skeletal base. theatres of Seattle Children’s Hospital under direction Regardless of group, each subject attempted laryngos- of faculty from the University of Washington School of copy with a Macintosh size 3 laryngoscope and intubation Medicine Department and Anaesthesiology. Advanced with a styletted 7.0 endotracheal tube, 25 times. An inves- training in surgical airway management is provided by tigator observed and scored the result of every attempt as the Director of Paramedic Training and the University success or failure. After training on the group-specific of Washington Department of Surgery in simulation manikin, all students attempted to intubate the adjustable laboratories. model with the mouth opening reduced from 5 cm to The data for analysis were collected as part of the 3.5 cm, a new configuration for all subjects. In addition, quality assurance process for the paramedic training. participants performed laryngoscopy with a different Data on each student’s intubation attempt were described airway manikin that none had seen, a Medical Plastics using measures of central tendency for continuous Airway model. Five attempts were recorded on each of the data and percentages for categorical data. Multi-variable two evaluation models. Success or failure for each attempt logistic regression, using GEEs with robust variance was assessed as in the training period. estimators, was used to assess the effect of cumulative The authors conducted the analysis by constructing experience on paramedic student pre-hospital intubation a mixed linear model to take account of the hierarchical success rates while adjusting for confounding variables. structure of the design; multiple measurements at different Cervical spine precautions in trauma, cardiac arrest and occasions were nested within each subject. rapid-sequence induction were considered as potential confounders in the analysis. The relationship between Paramedic self-efficacy and skill retention pre-hospital intubation success rate and total number of in pediatric airway management intubation attempts was summarised by plotting the pre- dicted success rate and 95% prediction intervals from the The aim of the study by Youngquist et al. (2008) was to regression equation as a function of cumulative number evaluate the effect of paediatric airway management of intubation attempts. training and periodic retraining on the self-efficacy and Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 13 skill performance of paramedics. They hypothesised that 1. How do paramedics learn the skill of intubation? an increase in both self-efficacy and skill performance 2. How do paramedics maintain the skill of would occur with both training and retraining and that intubation? the nature of the retraining programme would have a In order to answer these questions, it is first necessary statistically significant influence on both self-efficacy and to define when a paramedic is considered to have ‘learnt’ skill performance. the skill of intubation. Although all papers described This was a prospective, unblinded trial comparing various methods of learning intubation, including didactic three alternative retraining methods for paediatric airway lectures, manikin practice and live patient experience, management with a bag-valve-mask (BVM) and tracheal such as in operating theatres, emergency departments intubation. A convenience sample of 245 paramedics or out-of-hospital, few acknowledge that a definition of drawn from the Paediatric Airway Management Project, having learnt to intubate is not clearly defined. a paediatric airway management skills course that trained 2520 paramedics from two US EMS services, made up the participants for the study. They were allocated to one of Defining intubation skill proficiency/ four retraining groups: competency 1. No retraining (control group). Proficiency and competency were used interchangeably 2. A videotape demonstrating BVM and intubation within several studies in this review, and authors did not skills (the same training tape used to supplement always clearly define the terms, but all made an associa- initial training (videotape group)). tion with intubation success rates and/or complication 3. A self-directed learning method, in which para- rates as measures of becoming proficient/competent at medics were given instructional materials regard- intubation. Deakin et al. (2009) acknowledged that it was ing BVM and intubation skills. Paramedics were difficult to define the meaning of the word competent encouraged to practise skills in teams, using in relation to intubation, but intimated that intubation provided manikins and equipment (self-directed success is a measure of this. Wang et al. (2005) went group). 4. A lecture and demonstration by two instructors in further, stating that the number of intubation attempts addition to instructor-facilitated practice (lecture/ does not demonstrate the quality of performance. While demonstration group). they did define intubation proficiency in terms of the number of successful intubations, they also highlighted Subjects were asked to complete a 24-question self- that avoidance of technical errors, students’ laryngoscopy efficacy questionnaire both before and immediately after technique and sound decision-making should also be in initial training in paediatric airway management (and the mix, although admitted that this blend has not been prior to testing), and again before and after the retraining defined. Warner et al. (2010) specifically examined first session. Following completion of all questionnaires, para- attempt success at intubation as their primary outcome medics underwent paediatric airway management skills variable as they felt this was also a measure of minimising testing with the use of BVM and paediatric intubation on potential patient complications. a manikin. Performance was rated as fail, pass, high pass or honours for each skill. Both training and retraining If intubation success rates (either overall or first were performed by the same two research nurses, who also attempt) and complication rates are to be included in a scored paramedics on skills testing based on a written list definition of having successfully learnt the skill of intuba- of skill components. Passing required at least 70% comple- tion, then the acceptable percentage of both these rates tion of these skill components, high pass required at needs to be decided. Warner et al. (2010) defined a pre- least 80% and honours was awarded to those successfully hospital intubation success rate of 90% as an appropriate completing at least 90% of the skill components. target for the paramedic students in their study, and this Chi-square and Fisher’s exact tests were performed figure appeared in two other studies, although this was not to compare categorical variables. Generalised linear explicitly endorsed as a desirable target (Toda et al., 2013; models and t-tests were used to test differences in means Wang et al., 2005). of normally distributed continuous variables. Kruskal- Only Toda et al. (2013) provided any data about compli- Wallis tests were used to test for differences in location cations rates and these arguably have limited applicability between non-normally distributed continuous variables. since not all of them could be attributable to the intubation Finally, an ordinal logistic regression model was created attempt. In anaesthetised patients in the operating theatre, to describe the effects of the retraining method on scores they reported a complication rate of 53% decreasing obtained in airway skills testing. to 31% during the 30 intubation attempts the paramedic students made. The vast majority of complications were Discussion minor, either hoarseness or a sore throat, which are not likely to be of great concern to patients eligible for pre- The two key review questions that this RER aimed to hospital intubation. answer were: Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Table 2. Summary of study participants, outcomes and results. Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country 2 2 Survey undertaken Deakin et al. Retrospective, 269 paramedics with a PRF review: intubation success 128/269 paramedics (47.6%) had undertaken no intubation and 204 (75.8%) had undertaken one during transition to (2009) observational documented intubation rate, intubations per paramedic intubation or fewer in the 12-month study period. higher education. (PRF, review) attempt. Median number per annum, intubation attempts. May 2008 First-pass success occurred in 320/394 (81.2%) of Most likely historic of intubations during study LMA insertion also included. Prospective, UK attempts (no data recorded in 45 PRFs). picture of previous, period is 1 (range 0–11). observational Survey: LMA use by technicians/ vocational-style 15 ambulance services responded to survey. 13 (survey) 15 UK ambulance services paramedics, initial and ongoing requirements required intubations to be performed in theatre. 10 responded to survey. training for intubation and required 25 intubations, 2 required 20 (one of these LMA. had a caveat that this was acceptable if assessed as competent), 1 required 13 (if competent), 1 required 10, 1 required 5. For ongoing training, 3 services conducted annual manikin assessment, 2 conducted a mannikin assessment every 2 years and 1 sent paramedics to spend 1 day in theatre if number of intubations deemed inadequate. Hall et al. (2005) Prospective, 36 second-year paramedic Overall intubation success rate. Overall success rate 87.8% in SIM-only group and 84.8% 3 2 N/A interventional students with no prior in the OT group. First attempt success rate 84.4% May–Dec 2003 Intubation success, first attempt (RCT) intubation training or and 80% (SIM and OT groups respectively). Neither success, complications incl. Canada experience. statistically significant. dental trauma, airway bleeding, 540 patients (270 in each oxygen desaturation <85%, 11/18 students in the SIM group ≥ 13 successful group), mean age 43.0 years arrhythmias, oesophageal intubations. (range 3–88 years) in the intubation. 12/18 students in the OT group ≥ 12 successful SIM group and 44.1 years intubations. (range 15–87 years) in the The mean time to successful intubation was 47.2 OT group (p = 0.48). 12 seconds in the SIM group and 43.0 in the OT group, patients under 18 years in with a difference of 4.2 (95% CI = −0.5 to 8.8). the SIM group and 7 in the OT group (p = 0.24). The Skill acquisition during the process of testing did not study groups were well occur in either group, because the overall success matched for predictors of rates were consistent throughout the 15 test airway difficulty including: intubations. BMI, dentures, Mallampati Test intubations were interrupted for patient safety scores, thyromental distance, in 13 of 540 test intubations (2.4%). 8 of 270 test paralytic use and overall intubations (2.9%) in the SIM group and 5 of 270 airway difficulty. (1.9%) in the OT group were interrupted (p = 0.57). Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Reasons included airway difficulty (n = 5), ventricular arrhythmia during laryngoscopy (n = 1), anaesthetist unaware of study protocol (n = 1), student’s request (n = 1) and unspecified (n = 5). The mean time from training to testing was 7.5 weeks in the SIM group and 7.0 weeks in the OT group (p = 0.99). There was no difference between groups for the overall intubation success rate in students with longer delays between training and testing (p = 0.31) Johnston et al. Prospective, 161 programme directors Opportunity for intubation by Median time in theatres 17–32 hours. Half of 2 2 161/192 (85%) (2006) observational of CAAHEP accredited paramedic students. programmes provided < 16 hours per student. completed surveys paramedic training Median intubation attempts 6–10 per student. 58% returned June–Sept 2005 Average training hours per programmes. respondents reported increased competition for student. Average intubation USA operating theatre placements to practise intubation. attempts, student support, Increasing use of LMAs and medical-legal concerns graduate fulfilment of national highlighted in free text. recommendation of 5 intubations, access to operating Reduction in access identified by 52 programmes (32%) theatres over past 2–3 years. and 56 (35%) expected operating theatre placements to reduce in next 2–3 years. Levitan et al. Prospective, Paramedic students (no other Intubation success, number 113 students, comprising 4 years of paramedic classes 2 2 N/A (2001) interventional demographic data provided). of intubations per student. (1995–1998, i.e. control group), performed 783 (historic Differences between groups laryngoscope insertions. The mean intubation success 1995–1998 controls) in terms of participant age, rate was 46.7% (95% CI, 42.2–51.3%, SD ± 24.7%). USA gender and level of education. The range of laryngoscope insertions per student was 1–15 (mean 6.99, mode 6). In the video (intervention) group (paramedic classes 1998–1999), 36 students performed 102 laryngoscopies, with a mean individual success rate of 88.1% (95% CI, 79.6–96.5%, SD ± 25.9%). The range of insertions was 1–10 (mean 2.8, mode 3). Comparing the traditional group with the video group, the difference in success rates was statistically significant (P ≤ 0.0001; 46.7% vs. 88.1%, difference 41.4%, 95% CI, 31.1%–50.7%). The video and traditional groups did not differ in terms of age (25.0 vs. 26.1, P = 0.48), male sex (65.8% vs. 52.6%, P = 0.147) or level of education (87.5% grade 12 vs. 86.8% grade 12, P = 0.375). (continued) Table 2. (Continued) Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Plummer and Prospective, 115 students, mostly medical Models of intubation success. The rate of successful ETI increased from 6% on the 2 2 Owen and Plummer Owen (2001) interventional students (95), remainder first trial to approximately 80% after 15 trials. Trainees (2002) was critical care trainees and became familiar with an airway trainer after multiple not included 1 year, date student paramedics (13). trials, as demonstrated by a 50% decrease in the odds in this review not specified of successful ETI when starting on a new trainer. The (was primarily a (paper learning model indicated that a trainee learns about description of a new accepted May as much from 1 successful ETI as from 12 (95% CI, clinical simulation 2001) 2–23) failed trials. The log of the number of intubation unit). Did describe Australia attempts correlated with intubation success (OR 6.8, some data from this 95% CI, 4.3–11). Paramedic students were significantly study. Suggested better than medical students. Choice of instructor did paramedic students have a significant adverse effect on intubation success. approached 100% success after 6 attempts Toda et al. (2013) Prospective, 32 paramedics, no details on How much does the success 32 paramedics attempted 1049 intubations. 4 attempts 3 2 Unclear whether interventional selection. rate of tracheal intubation aborted. 1 due to no vocal cord visualisation, 1 due to skillset of Jan 2005–Dec by paramedics improve over tooth mobility and 2 because of dental damage during paramedics in Japan 2011 Patients: healthy surgical the course of the 30 live BVM ventilation. comparable with UK patients who required Japan experiences? intubation as part of their Only data for each trainee’s first 30 patients were used anaesthetic management and How much is the frequency to avoid survival bias, giving 960 observations for who were: aged 20 years or of complications possibly analysis. older, ASA physical status associated with tracheal Overall success rate increased from 71% to 87% (CI, class I or II and no evidence intubation decrease? 82–94%) after training on 30 patients. Used model of a potentially difficult to predict number of attempts required for 90% and airway. 95% success: 31.5 (95% CI, 27.6–54.3) and 38.6 (CI, 31.2–76.9). Complications all minor. Overall complication rate decreased from 53% to 31% after 30 patients. No significant learning up to 13 experiences with fastest learning period around 19 intubations. Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Wang et al. Retrospective, 891 students from 60 Relationship between intubation Mean number of intubations per student 9.5 (median 7, 2 2 N/A (2005) observational paramedics programmes in success and cumulative number IQR 4–12). Self-reported intubation success. Overall USA, 802 attempted a total of intubations. 87.5% (95% CI, 86.7–88.2), pre-hospital (n = 903) May 1999–Dec of 7635 ETIs. No ETIs were success 74.8% (71.9–77.6%). reported by 89 students. Learning curve for paramedics increased from 77.8% USA Only first 30 intubation to 95.8% over 30 ETI procedures. When stratified attempts included, leaving by clinical setting, suggests more than 30 intubations 7398 intubations for study required to achieve >90% success rate with pre- inclusion. No student or hospital intubations. patient demographics available. Warner et al. Retrospective, 56 paramedic students from Primary outcome successful 56 paramedic students in 3 consecutive classes 3 2 N/A (2010) observational Seattle Fire Department. placement of an ETT in completed training and were included in study. 1616 No other details. the trachea by the student, intubations attempted (median 29 intubations per 3 years, no start regardless of number of student), 706 intubations in operating theatres and date (paper attempts. 576 in pre-hospital setting. submitted Jan 2009) Secondary outcome. Pre-hospital intubation success 88% for all students, first-pass success 66%. USA First-pass success rates for student ETI attempts in the Odds of intubation success increased by 1.097 for each pre-hospital setting. successive patient (95% CI, 1.026–1.173). First-pass success OR 1.061 (1.014–1.109). Cumulative exposure to pre-hospital intubation most important factor in pre-hospital success. First-pass success of 90% requires more than 20 attempts. Wong et al. Prospective, 51 paramedic students in their Intubation success or failure and Overall 88% ± 1% success rate. first-pass success 3 2 N/A (2011) interventional second month of training and time to intubation. 65–70%. Success rate improved with number of 18 medical students, including attempts (OR 1.06, 95% CI, 1.03–1.08). Paramedic No study period 12 first-year, 3 second-year, students more likely to succeed than medical specified and 3 fourth-year students. students. Students trained on the novel trainer in a (paper static configuration were less likely to be successful accepted at intubating compared to the group using the Laerdal Aug 2010) airway trainer. USA A recent change in airway model reduced the odds of success to 70% of the odds without a change. However, practising laryngoscopy in a new airway model adjusted into 5 different configurations did not improve the odds of success over practising with only an airway trainer held in a fixed anatomy. (continued) Table 2. (Continued) Citation, data Study type Participant details Outcomes/outcome measures Results CAS REL Comment collection period and country Youngquist et al. Prospective, 245 paramedics, 184 male, Self-reported confidence and Paramedics from low-call-volume areas reported lower 3 2 N/A (2008) interventional median years as paramedic 8 anxiety performing BVM and baseline self-efficacy and derived larger increases (IQR 4–13), 141 paramedics ETI. Skills performance. with training, but also experienced the most decline 24 months, date were parents, total runs and between training events. Pass rates for BVM and ETI not specified Mean change between self- paediatric runs per 24hr were 66% (139⁄211) and 42% (88⁄212), respectively. (paper efficacy scores and skill reported, months since received April performance. Overall cohort self-efficacy was maintained over the elapsed training median 13 2008) study period. In ordinal regression modelling, only (IQR 7–16). Demographics the lecture and demonstration method was superior per group also included. to control, with an OR of achieving higher scores of 2.5 (95% CI = 1.2–5.2) for BVM and 5.2 (95% CI, 2.4–11.2) for intubation. Poor performance with intubation but not BVM was associated with time elapsed since training (p = 0.01). Self-efficacy ratings were not predictive of skill performance. ASA = American Society of Anesthesiologists; BMV = bag-valve-mask; CAAHEP = Commission on Accreditation of Allied Health Education Programmes; CAS = critical appraisal score; CI = confidence interval; ETI = endotracheal intubation; IQR = interquartile range; LMA = laryngeal mask airway; OR = odds ratio; OT = operating theatre; PRF = patient report form; RCT = randomised controlled trial; REL = relevance score; SIM = simulation. Pilbery 19 (Plummer & Owen, 2001; Wong et al., 2011); one exam- The learning curve for intubation ined the use of videos from the point of view of a laryngo- Three papers aimed to model the relationship between the scopist as part of the students’ training (Levitan et al., number of intubation attempts and intubation success 2001), and one aimed to determine whether training (Toda et al., 2013; Wang et al., 2005; Warner et al., 2010). intubations in the operating theatre could be replaced by Toda et al. (2013) examined 960 intubation attempts by training on a high-fidelity simulator (Hall et al., 2005). 32 Japanese paramedics. Having modelled the data, they Plummer and Owen (2001) used six different airway determined that 31.5 attempts were required for an overall trainers (one had two configurations, with and without 90% intubation success rate (i.e. all attempts, not just first) a cervical collar applied, making seven different airway with a 95% CI ranging from 27.6 to 54.3 attempts. In addi- trainers overall). They found that the students’ success tion, the relationship between probability of success and rate was the log of the number of intubation attempts, with the cumulative number of attempts was S-shaped, with a an initial steep learning curve that plateaued after approxi- plateau in intubation success rates for the first 13 attempts, mately 12 attempts. However, changing the airway trainer suggesting limited learning, before a sharp rise in success reduced the odds of a successful intubation by 50%. rates at around 19 intubation attempts. However, care Only 13 of the 100 students were paramedics and it needs to be taken when extrapolating models beyond the appeared that the instructor facilitating the event had an range of the data provided, and it is not clear how similar impact on intubation success. In addition, the allocation Japanese paramedics are to UK paramedic students. of airway trainer was not consistent, making these results Finally, all these intubations took place in the operating less reliable and applicable to paramedics. theatre and were chosen by the supervising anaesthetist, Wong et al. (2011) also tested multiple airway trainers. which might not reflect the challenges of pre-hospital Their motivation was in part due to the difficulty in obtain- intubation attempts. ing live patient experiences for non-anaesthetists as well This difference in location where the intubation was as recognising that training on a single model does not performed was incorporated into the analysis of the translate to good performance on different manikins (or Warner et al. (2010) and Wang et al. (2005) studies. Warner real patients). They developed a novel airway trainer with et al. (2010) found a significant, positive relationship adjustable anatomy. As with the Plummer and Owen between cumulative intubation attempts. In contrast to (2001) study, not all of the students were paramedics, Toda et al. (2013), overall success rates plateaued at around although most were (51 paramedic students and 18 medical 10–15 intubations, although the starting success rate in this students). On modelling the data, they too noticed a decline cohort was above 80%, compared to Toda et al.’s (2013) (although a more modest 30% reduction) in intubation paramedics with a success rate of around 70%. However, success when changing airway trainer. when only first attempt success was examined, intubation Levitan et al. (2001) introduced a video showing success rates started at around 60%, rising to approxi- 15 laryngoscopies from the point of view of the laryngo- mately 80% after 20 attempts, leading the authors to con- scopist, which, at the turn of the millennium, was proba- clude that more than 20 attempts would be required to bly very novel. However, these videos are now easy to obtain a first-attempt intubation success rate of 90%. find on social media, but nonetheless compared to the In contrast to the other two studies in this section, Wang control group, who only had simple line drawings and et al. (2005) conducted a retrospective review of Fisdap; manikin anatomy, this appeared to be an advantage when an internet-based system used to record paramedic student the students went to operating theatres to practise intuba- clinical and procedural experience. While not interven- tion. The mean success rate for the video group was 88.1% tional, it did allow the authors to extend their scope beyond (95% CI, 79.6–96.5%) compared to the control group a single centre. They included 7635 intubation attempts (no video) mean of 46.7% (95% CI, 42.2–51.3%). This from 802 paramedic students on 60 paramedic programmes study did use historic controls, so it is possible that other across North America. Like Warner et al. (2010), they strat- confounding factors have not been taken into account. ified their results in order to model intubation success rates Given the limited opportunities to gain intubation by location, and found a significant relationship between experience in operating theatres for paramedic students cumulative intubation attempts and probability of intubation (Deakin et al., 2009; Johnston et al., 2006) both in the UK success. Overall, intubation success rates increased from and the US, it is no surprise that a study has been con- 77.8% to 95.8% over 30 intubation attempts. However, ducted to see whether some of these intubation attempts when examining pre-hospital intubations, success rates on live patients could be replaced by high-fidelity simula- started at around 50%, rising to in excess of 85% after tion. Hall et al. (2005) conducted an RCT with a group of 30 attempts. They drew the conclusion that more than 42 paramedic students. Having completed the standard 15–25 live intubations, preferably in a range of settings, airway training curriculum consisting of 20 hours of were required to reach acceptable intubation success rates. didactic and video training, supplemented with 10 hours of practice on a manikin, students were randomised into Intubation training aids either receiving 10 hours of training on a high-fidelity Two papers in the review examined the use of different simulator (METIman) facilitated by an anaesthetist and manikin types as part of paramedic airway education senior emergency department doctor, or being in the Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 20 British Paramedic Journal 3(2) control group and going to theatres to perform 15 population, although this would have potentially made intubation attempts. Students in the intervention arm findings less relevant to paramedics. (simulation group) completed an ‘average’ of 50 intuba- tions on the simulator. Following this, both groups were Conclusion assessed in the operating theatre by performing 15 intuba- tion attempts. The first-attempt success rates were 84.4% In order to determine how paramedics learn and maintain and 80.0% in the simulation and control group, respec- the skill of intubation, a definition is required so it is clear tively, which was a non-significant difference. This led to what benchmark is to be used to state that a paramedic the conclusion that paramedic students could be trained on has ‘learnt’ the skill of intubation. This could be a single high-fidelity simulators as effectively as traditional live measure such as first-pass success of 90% for pre-hospital patient intubation when assessed in the operating theatre. intubation, for example, or a range of measures, such as While Hall et al. (2005) do acknowledge the cost of the intubation success and complication rates, laryngoscopy manikin as an issue, the possibility that the experience technique and decision-making. of the faculty also contributed to the performance of the The precise number of intubations required to become simulator group was not considered. proficient at intubation is not clear, but based on the evi- dence in the review, to achieve a first-pass intubation success rate of 90%, paramedic students require 25–30 Maintaining the skill of intubation intubations on live patients, preferably in a range of Compared to skill acquisition, there was a paucity of environments (e.g. commencing in operating theatres evidence that specifically addressed how paramedics or other in-hospital settings and then out-of-hospital). maintained proficiency/competence in the skill of intuba- Additional intubations are desirable, either with live tion. Two papers (Deakin et al., 2009; Youngquist et al., patients or on high-fidelity manikins. 2008) in the review addressed this issue, although Deakin Intubation training should use a range of modalities, et al. (2009) conducted a telephone survey of training including didactic lectures, videos and practical sessions schools in 2008, which is unlikely to provide more than on airway manikins. Students should not be trained on a historic view of the maintenance of advanced airway only a single manikin, but should have access to multiple skills. The study by Youngquist et al. (2008), however, did types. Supervision by experienced faculty is required. examine the performance of paramedics between two time Little is known about how paramedics maintain their points (a median of 13 months, IQR 7–16 for all groups). skill in intubation, given the lack of clinical opportunity. Although the study only considered intubation in children, Yearly skills retraining can help, and can be enhanced by there was a significant decline in skills performance as demonstrations/lectures from experienced faculty. time to retraining increased (odds ratio (OR) 0.93, 95% CI, Further research is needed to understand how para- 0.87–0.98). As an RCT evaluating different types of train- medics maintain their skill in intubation, given the limited ing modality (video only, self-directed learning or lecture opportunities to use the skill in a clinical setting and and demonstration by instructors followed by instructor- lack of opportunities with UK ambulance services for facilitated practice), the study also revealed that the only retraining. retraining intervention that had a significant increase in skills performance was the lecture/demonstration group Acknowledgements (OR 5.17, IQR 2.39–11.19). These results suggest that good quality retraining can help in improving skills perfor- Thanks to Professor Julia Williams from the College of mance (at least during an assessment on a paediatric Paramedics’ Airway Working Group for her assistance in manikin), especially in a patient group where clinical developing the protocol for this rapid evidence review. In exposure is likely to be limited. addition, the support from the librarian at the University of Hertfordshire, who provided some early guidance on potential search terms and MESH headings for the Limitations literature review, also deserves recognition. There are a number of important limitations with this review. The most significant is the methodology. Although Conflict of interest RERs do emulate aspects of a systematic review, they are not as comprehensive due to time and resource con- Richard Pilbery is the Editor of the British Paramedic straints. It is possible that relevant papers were not included Journal. in the review. In addition, the RER was conducted by a single person (RP), which may have resulted in papers Funding being excluded from the study inappropriately. Finally, given the limited data to inform the research question, it This report was commissioned and paid for by the College may have been prudent to have widened the eligible of Paramedics. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21 Pilbery 21 in an operating room setting. Annals of Emergency References Medicine, 37, 46–50. College of Paramedics. (2008, September). College of Owen, H., & Plummer, J. L. (2002). Improving learning of a Paramedics (British Paramedic Association) updated clinical skill: The first year’s experience of teaching position paper following JRCALC recommendations on endotracheal intubation in a clinical simulation facility. paramedic intubation. Retrieved from https://www. Medical Education, 36, 635–642. collegeofparamedics.co.uk/downloads/College_of_ Plummer, J. L., & Owen, H. (2001). Learning endotracheal Paramedics_post_report_intubation_position_paper_ intubation in a clinical skills learning center: A V4.pdf. quantitative study. Anesthesia and Analgesia, 93, 656. Collins, A., Coughlin, D., Miller, J., & Kirk, S. (2016, October Toda, J., Toda, A. A., & Arakawa, J. (2013). Learning curve for 17). The production of quick scoping reviews and rapid paramedic endotracheal intubation and complications. evidence assessments. Retrieved from https://www.gov. International Journal of Emergency Medicine, 6, 1–8. uk/government/publications/the-production-of-quick- Wang, H. E., Seitz, S. R., Hostler, D., & Yealy, D. M. (2005). scoping-reviews-and-rapid-evidence-assessments. Defining the learning curve for paramedic student Deakin, C. D., King, P., & Thompson, F. (2009). Pre-hospital endotracheal intubation. Prehospital Emergency Care, 9, advanced airway management by ambulance technicians 156–162. and paramedics: Is clinical practice sufficient to maintain Warner, K. J., Carlbom, D., Cooke, C. R., Bulger, E. M., skills? Emergency Medicine Journal, 26, 888–891. Copass, M. K., & Sharar, S. R. (2010). Paramedic training Ganann, R., Ciliska, D., & Thomas, H. (2010). Expediting for proficient pre-hospital endotracheal intubation. systematic reviews: Methods and implications of rapid Prehospital Emergency Care, 14, 103–108. reviews. Implementation Science, 5, 56. Wong, W., Kedarisetty, S., Delson, N., Glaser, D., Moitoza, J., Hall, R. E., Plant, J. R., Bands, C. J., Wall, A. R., Kang, J., Davis, D. P., & Hastings, R. H. (2011). The effect of cross- & Hall, C. A. (2005). Human patient simulation is training with adjustable airway model anatomies on effective for teaching paramedic students endotracheal laryngoscopy skill transfer. Anesthesia and Analgesia, intubation. Academic Emergency Medicine, 12, 113, 862–868. 850–855. Younger, P., Pilbery, R., & Lethbridge, K. (2016). A survey of Johnston, B. D., Seitz, S. R., & Wang, H. E. (2006). Limited paramedic advanced airway practice in the UK. British opportunities for paramedic student endotracheal Paramedic Journal, 1, 9–22. intubation training in the operating room. Academic Youngquist, S. T., Henderson, D. P., Gausche-Hill, M., Emergency Medicine, 13, 1051–1055. Goodrich, S. M., Poore, P. D., & Lewis, R. J. (2008). Levitan, R. M., Goldman, T. S., Bryan, D. A., Shofer, F., & Paramedic self-efficacy and skill retention in pediatric Herlich, A. (2001). Training with video imaging improves airway management. Academic Emergency Medicine, the initial intubation success rates of paramedic trainees 15, 1295–1303. Pilbery, R, British Paramedic Journal 2018, vol. 3(2) 7–21

Journal

British Paramedic JournalPubmed Central

Published: Sep 1, 2018

References