Understanding the Cognitive Demands, Skills, and Assessment Approaches for Endotracheal Intubation: Cognitive Task Analysis

Abstract

Background Proper airway management is an essential skill for hospital personnel and rescue services to learn, as it is a priority for the care of patients who are critically ill. It is essential that providers be properly trained and competent in performing endotracheal intubation (ETI), a widely used technique for airway management. Several metrics have been created to measure competence in the ETI procedure. However, there is still a need to improve ETI training and evaluation, including a focus on collaborative research across medical specialties, to establish greater competence-based training and assessments. Training and evaluating ETI should also incorporate modern, evidence-based procedural training methodologies. Objective This study aims to use the cognitive task analysis (CTA) framework to identify the cognitive demands and skills needed to proficiently perform a task, elucidate differences between novice and expert performance, and provide an understanding of the workload associated with a task. The CTA framework was applied to ETI to capture a broad view of task and training requirements from the perspective of multiple medical specialties. Methods A CTA interview was developed based on previous research into the tasks and evaluation methods of ETI. A total of 6 experts from across multiple medical specialties were interviewed to capture the cognitive skills required to complete this task. Interviews were coded for main themes, subthemes in each category, and differences among specialties. These findings were compiled into a skills tree to identify the training needs and cognitive requirements of each task. Results The CTA revealed that consistency in equipment setup and planning, through talk or think-aloud methods, is critical to successfully mastering ETI. These factors allow the providers to avoid errors due to patient characteristics and environmental factors. Variation among specialties derived primarily from the environment in which ETI is performed, subsequent treatment plans, and available resources. Anesthesiology typically represented the most ideal cases with a large potential for training, whereas paramedics faced the greatest number of constraints based on the environment and available equipment. Conclusions Although the skills tree cannot perfectly capture the complexity and detail of all potential cases, it provided insight into the nuanced skills and training techniques used to prepare novices for the variability they may find in practice. Importantly, the CTA identified ways in which challenges faced by novices may be overcome and how this training can be applied to future cases. By making these implicit skills and points of variation explicit, they can be better translated into teachable details. These findings are consistent with previous studies looking at developing improved assessment metrics for ETI and expanding upon their work by delving into methods of feedback and strategies to assist novices.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

“…The broader literature suggests specific opportunities for enhanced feedback to EMS personnel, such as combined audit and patient outcome feedback to improve decision-making81–84 for specific patient presentations (eg, cardiac arrest,85–93 myocardial infarction,94–96 stroke,97 98 abdominal pain,99 paediatrics,100 trauma101 102). Furthermore, patient outcome feedback may improve staff mental health and learning103–109 for patients not conveyed to hospital,110 with non-specific complaints,111 with significant differences between EMS and in-hospital diagnoses112 and patients referred to the coroner,113 while increased audit and feedback of particular skills (eg, intubation,114 ultrasound115) or situations (eg, handover,116 117 triage118) may improve performance. Lastly, increasing peer-to-peer and patient outcome feedback for certain staff groups may provide peer support and improve patient management skills for newly qualified119 120 and specialist paramedics 121–126…”

Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis

“…We found that non-channeled VLs do not improve outcomes over DL, and this may be due to difficulty in navigating the endotracheal tube despite the visualization of the glottis [14,19]. Channeled VL requires less complex maneuvering and decreases cognitive load, creating a safer learning environment [7,11].…”