138
| Correspondence
Increasing opportunities for intubation training for foundation doctors D. Cummings* and A. Rajkumar South Tyneside, UK *E-mail: [email protected]
Editor—We read with great interest the article1 stating that there was no significant increase in incidence of sore throat or hoarseness between trainees and consultants when undertaking intubation. As current foundation doctors, we have previously been refused requests to intubate patients under supervision because of concerns about perceived increased risk of poor technique and the potential for patient injury. We were lucky enough to go on to develop this skill during an anaesthetics rotation and feel that more advanced airway training has been extremely beneficial to both our confidence and competence in subsequent placements throughout foundation training. It is interesting to note that Deakin and colleagues2 found that even junior doctors who had undergone advanced life support training did not show adequate competency in delivering highquality airway support and ventilation in an anaesthetized patient in comparison to anaesthetic trainees. Although advanced life support does not explicitly cover the techniques of intubation, and this study focused on the demonstration of manual ventilation and insertion of a supraglottic device, adequate airway control and ventilation is a key component in the preoxygenation phase of intubation, which would be gained by association through training in this technique. Airway management is one of the most fundamental skills for a trainee to develop in order to provide safe and competent patient care, especially in the acute setting. Articles such as this serve to increase the ability for foundation doctors to gain access
to the development of key practical skills, which are increasingly difficult to obtain given the shifts in training programmes over recent years with the implementation of the European Working Time Directive. It would be of interest to see the incidence of airway trauma between trainees and consultants because this could further allow for the implementation of intubation training for foundation doctors. Although intubation is not a skill that should be performed unsupervised by trainees, increasing the capability of junior colleges to manage a compromised airway appropriately serves only to improve the confidence and skill of foundation doctors in acute patient care, and development of these skills should be encouraged universally.
Declaration of interest None declared.
References 1. Inoue S, Abe R, Tanaka Y, Kawaguchi M. Tracheal intubation by trainees does not alter the incidence or duration of postoperative sore throat and hoarseness: a teaching hospitalbased propensity score analysis. Br J Anaesth 2015; 115: 463–9 2. Deakin CD, Murphy D, Couzins M, Mason S. Does an advanced life support course give non-anaesthetists adequate skills to manage an airway? Resuscitation 2010; 81: 539–43 doi:10.1093/bja/aew167
Reply from the author
Achieving both patient safety and developing trainees’ airway skills S. Inoue* Nara, Japan *E-mail: [email protected]
Editor—Thank you very much for your interest in our article.1 I sympathize with how you feel when you were refused requests to intubate patients under supervision. In our institute, at the medical interview for obtaining informed consent, patients often state that they would like to be managed by experienced anaesthetists, especially in instances of laryngoscopy and intubation. The patients may be concerned about perceived increased risk of poor technique and the potential for patient injury. It has been suggested that urgent or emergency intubations outside the operating room are associated with a much higher complication rate than intubations in elective conditions in the operating room.2–4 Therefore, airway complications because of physician inexperience may be more frequent in critical care settings; however, airway complications resulting from physician inexperience may be prevented by supervision in elective conditions in the operating room.
Reported airway complications in critical care settings, such as aspiration, oesophageal intubation, dental injury, and pneumothorax, are more serious than those usually encountered in non-emergency conditions but also more preventable. In comparison, complications such as sore throat or hoarseness are minor but relatively inevitable adverse events. Even with experience, further reduction may be limited, which could explain why these complication rates were no higher when intubation was performed by residents. However, incidence rates can increase without appropriate supervision even in elective conditions in the operating room. It has been reported that airway complications decrease significantly when supervision is given by an experienced anaesthetist, even in the critical care setting. Therefore, appropriate supervison plays a pivotal role for trainees both to achieve patient safety and to develop their airway skills.
Correspondence
Declaration of interest None declared.
References 1. Inoue S, Abe R, Tanaka Y, Kawaguchi M. Tracheal intubation by trainees does not alter the incidence or duration of postoperative sore throat and hoarseness: a teaching hospitalbased propensity score analysis. Br J Anaesth 2015; 115: 463–9
| 139
2. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. Anesthesiology 1995; 82: 367–76 3. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004; 99: 607–13 4. Benedetto WJ, Hess DR, Gettings E, et al. Urgent tracheal intubation in general hospital units: an observational study. J Clin Anesth 2007; 19: 20–4 doi:10.1093/bja/aew168
CUMSUM cannot define competency K. K. Srinivasan*, N. O’Brien and G. Shorten Cork, Ireland *E-mail: [email protected]
Editor—Drake and colleagues1 have addressed the drawbacks of CUMSUM analysis, namely self-reporting and small sample size. They have also broadened the definition of failure to increase the sensitivity. We would like to highlight some related issues. Procedural skill proficiency can lead to better patient outcomes.2 However, substandard performance does not invariably lead to poor patient outcome. For example, poor aseptic technique during a procedure such as placement of an epidural catheter does not necessarily affect the (analgesic) success of the procedure, at least in the short term. Nonetheless, it is clearly unacceptable. Hence, the concept of defining competency based only on failure rates is inherently flawed. We suggest that ascertaining competency for a particular procedure first requires establishment of a benchmark of proficiency for that procedure. This should be based on unambiguous, objective, and validated metrics. Each procedure ( performed by each trainee or not) can then be assessed based on these benchmarks. A practitioner can then be deemed competent once he or she meets the benchmarks consistently. This concept of proficiency training has been described in detail elsewhere.3 This approach should enable trainees to receive prompt, specific, and objective feedback on their performances. The ability to give feedback on performance is one of the key factors in deliberate practice and is absent in CUMSUM.4
We disagree with the authors’ conclusion that ‘CUMSUM is an effective tool in charting the development of competence for trainees’; efficacy requires that meaningful change in performance standard is captured, which is a condition not met if success or failure alone is measured.
Declaration of interest None declared.
References 1. Drake EJ, Coghill J, Sneyd JR. Defining competence in obstetric epidural anaesthesia for inexperienced trainees. Br J Anaesth 2015; 114: 951–7 2. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013; 369: 1434–42 3. Gallagher AG. Metric-based simulation training to proficiency in medical education:- what it is and how to do it. Ulster Med J 2012; 81: 107–13 4. Bolsin S, Colson M. The use of the Cusum technique in the assessment of trainee competence in new procedures. Int J Qual Health Care 2000; 12: 433–8 doi:10.1093/bja/aew160
Reply E. J. Drake1,* and J. R. Sneyd2 1
Derriford, UK, and 2Plymouth, UK
*E-mail: [email protected]
Editor—We thank Drs Srinivasan, O’Brien, and Shorten for their interest in our article. Obstetric epidural practice for the trainee, once deemed competent by experienced trainers, most often
occurs out of hours. In this situation, because much of the trainee’s work is unsupervised it is difficult to gain an insight on a trainee’s performance in a particular procedural skill.
| Correspondence
Increasing opportunities for intubation training for foundation doctors D. Cummings* and A. Rajkumar South Tyneside, UK *E-mail: [email protected]
Editor—We read with great interest the article1 stating that there was no significant increase in incidence of sore throat or hoarseness between trainees and consultants when undertaking intubation. As current foundation doctors, we have previously been refused requests to intubate patients under supervision because of concerns about perceived increased risk of poor technique and the potential for patient injury. We were lucky enough to go on to develop this skill during an anaesthetics rotation and feel that more advanced airway training has been extremely beneficial to both our confidence and competence in subsequent placements throughout foundation training. It is interesting to note that Deakin and colleagues2 found that even junior doctors who had undergone advanced life support training did not show adequate competency in delivering highquality airway support and ventilation in an anaesthetized patient in comparison to anaesthetic trainees. Although advanced life support does not explicitly cover the techniques of intubation, and this study focused on the demonstration of manual ventilation and insertion of a supraglottic device, adequate airway control and ventilation is a key component in the preoxygenation phase of intubation, which would be gained by association through training in this technique. Airway management is one of the most fundamental skills for a trainee to develop in order to provide safe and competent patient care, especially in the acute setting. Articles such as this serve to increase the ability for foundation doctors to gain access
to the development of key practical skills, which are increasingly difficult to obtain given the shifts in training programmes over recent years with the implementation of the European Working Time Directive. It would be of interest to see the incidence of airway trauma between trainees and consultants because this could further allow for the implementation of intubation training for foundation doctors. Although intubation is not a skill that should be performed unsupervised by trainees, increasing the capability of junior colleges to manage a compromised airway appropriately serves only to improve the confidence and skill of foundation doctors in acute patient care, and development of these skills should be encouraged universally.
Declaration of interest None declared.
References 1. Inoue S, Abe R, Tanaka Y, Kawaguchi M. Tracheal intubation by trainees does not alter the incidence or duration of postoperative sore throat and hoarseness: a teaching hospitalbased propensity score analysis. Br J Anaesth 2015; 115: 463–9 2. Deakin CD, Murphy D, Couzins M, Mason S. Does an advanced life support course give non-anaesthetists adequate skills to manage an airway? Resuscitation 2010; 81: 539–43 doi:10.1093/bja/aew167
Reply from the author
Achieving both patient safety and developing trainees’ airway skills S. Inoue* Nara, Japan *E-mail: [email protected]
Editor—Thank you very much for your interest in our article.1 I sympathize with how you feel when you were refused requests to intubate patients under supervision. In our institute, at the medical interview for obtaining informed consent, patients often state that they would like to be managed by experienced anaesthetists, especially in instances of laryngoscopy and intubation. The patients may be concerned about perceived increased risk of poor technique and the potential for patient injury. It has been suggested that urgent or emergency intubations outside the operating room are associated with a much higher complication rate than intubations in elective conditions in the operating room.2–4 Therefore, airway complications because of physician inexperience may be more frequent in critical care settings; however, airway complications resulting from physician inexperience may be prevented by supervision in elective conditions in the operating room.
Reported airway complications in critical care settings, such as aspiration, oesophageal intubation, dental injury, and pneumothorax, are more serious than those usually encountered in non-emergency conditions but also more preventable. In comparison, complications such as sore throat or hoarseness are minor but relatively inevitable adverse events. Even with experience, further reduction may be limited, which could explain why these complication rates were no higher when intubation was performed by residents. However, incidence rates can increase without appropriate supervision even in elective conditions in the operating room. It has been reported that airway complications decrease significantly when supervision is given by an experienced anaesthetist, even in the critical care setting. Therefore, appropriate supervison plays a pivotal role for trainees both to achieve patient safety and to develop their airway skills.
Correspondence
Declaration of interest None declared.
References 1. Inoue S, Abe R, Tanaka Y, Kawaguchi M. Tracheal intubation by trainees does not alter the incidence or duration of postoperative sore throat and hoarseness: a teaching hospitalbased propensity score analysis. Br J Anaesth 2015; 115: 463–9
| 139
2. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. Anesthesiology 1995; 82: 367–76 3. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004; 99: 607–13 4. Benedetto WJ, Hess DR, Gettings E, et al. Urgent tracheal intubation in general hospital units: an observational study. J Clin Anesth 2007; 19: 20–4 doi:10.1093/bja/aew168
CUMSUM cannot define competency K. K. Srinivasan*, N. O’Brien and G. Shorten Cork, Ireland *E-mail: [email protected]
Editor—Drake and colleagues1 have addressed the drawbacks of CUMSUM analysis, namely self-reporting and small sample size. They have also broadened the definition of failure to increase the sensitivity. We would like to highlight some related issues. Procedural skill proficiency can lead to better patient outcomes.2 However, substandard performance does not invariably lead to poor patient outcome. For example, poor aseptic technique during a procedure such as placement of an epidural catheter does not necessarily affect the (analgesic) success of the procedure, at least in the short term. Nonetheless, it is clearly unacceptable. Hence, the concept of defining competency based only on failure rates is inherently flawed. We suggest that ascertaining competency for a particular procedure first requires establishment of a benchmark of proficiency for that procedure. This should be based on unambiguous, objective, and validated metrics. Each procedure ( performed by each trainee or not) can then be assessed based on these benchmarks. A practitioner can then be deemed competent once he or she meets the benchmarks consistently. This concept of proficiency training has been described in detail elsewhere.3 This approach should enable trainees to receive prompt, specific, and objective feedback on their performances. The ability to give feedback on performance is one of the key factors in deliberate practice and is absent in CUMSUM.4
We disagree with the authors’ conclusion that ‘CUMSUM is an effective tool in charting the development of competence for trainees’; efficacy requires that meaningful change in performance standard is captured, which is a condition not met if success or failure alone is measured.
Declaration of interest None declared.
References 1. Drake EJ, Coghill J, Sneyd JR. Defining competence in obstetric epidural anaesthesia for inexperienced trainees. Br J Anaesth 2015; 114: 951–7 2. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013; 369: 1434–42 3. Gallagher AG. Metric-based simulation training to proficiency in medical education:- what it is and how to do it. Ulster Med J 2012; 81: 107–13 4. Bolsin S, Colson M. The use of the Cusum technique in the assessment of trainee competence in new procedures. Int J Qual Health Care 2000; 12: 433–8 doi:10.1093/bja/aew160
Reply E. J. Drake1,* and J. R. Sneyd2 1
Derriford, UK, and 2Plymouth, UK
*E-mail: [email protected]
Editor—We thank Drs Srinivasan, O’Brien, and Shorten for their interest in our article. Obstetric epidural practice for the trainee, once deemed competent by experienced trainers, most often
occurs out of hours. In this situation, because much of the trainee’s work is unsupervised it is difficult to gain an insight on a trainee’s performance in a particular procedural skill.
