The Journal of Emergency Medicine, Vol. 48, No. 5, pp. 613–619, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.029
Education DO EMERGENCY MEDICINE RESIDENTS RECEIVE APPROPRIATE VIDEO LARYNGOSCOPY TRAINING? A SURVEY TO COMPARE THE UTILIZATION OF VIDEO LARYNGOSCOPY DEVICES IN EMERGENCY MEDICINE RESIDENCY PROGRAMS AND COMMUNITY EMERGENCY DEPARTMENTS Anand Kumar Swaminathan, MD, MPH, Rachel Berkowitz, MD, Annalee Baker, MD, and Meghan Spyres, MD Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital, New York, New York Reprint Address: Anand Kumar Swaminathan, MD, MPH, Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital, 462 1st Ave., OBV-A341, New York, NY 10016
, Abstract—Background: Video laryngoscopy (VL) has emerged as a critical tool in the ‘‘difficult airway’’ armamentarium of emergency physicians. The resultant increase in the types of available VL devices has made Emergency Medicine Residency (EMR) training in VL increasingly challenging. Additionally, the prevalence of VL devices in the community is unknown. Because Emergency Medicine (EM) residents go on to work in diverse settings, many in non-EMR emergency departments (EDs), it is preferable that they receive training on the airway modalities they will encounter in practice. Objective: To compare the prevalence and type of VL devices in EMR programs to nonEMR EDs. Methods: This was a survey study conducted from July 2012 to October 2012 of Accreditation Council for Graduate Medical Education-accredited, MD EMR programs in the United States and non-EMR EDs in New York State. A chi-squared test was performed to determine whether the difference in VL prevalence was significant. Results: There were 158 EMR programs and 132 non-EMR
EDs surveyed; 97.8% of EMR and 84.3% of non-EMR EDs reported having some form of VL in their departments. The difference in proportion of EMR vs. non-EMR EDs that have VL was c2 = 13 (p < 0.001). The GlidescopeÒ device (Verathon Medical, Bothell, WA) was present in 87.7% of EMR programs and 79.3% of non-EMR EDs. Conclusions: The majority of EMR programs trained residents in VL. The Glidescope device was used most frequently. Non-EMR EDs in New York State had a lower presence of VL devices, with the Glidescope device again being the most common. These results demonstrate that VL is pervasive in both practice environments. Ó 2015 Elsevier Inc. , Keywords—airway; video laryngoscopy; direct laryngoscopy; Glidescope; resident education
INTRODUCTION Direct laryngoscopy (DL) represents the conventional approach to intubation in the emergency department (ED). For many years, Emergency Medicine Residency (EMR) programs have focused resident airway training on developing DL skills. Over the last decade, various video laryngoscopy (VL) devices have emerged and are being used with increasing frequency in both EMR programs and non-EMR EDs (1–7). Whereas DL requires alignment of the pharyngeal, laryngeal, and tracheal
The work contained in this paper was presented at the Society of Academic Emergency Medicine (SAEM) Mid Atlantic Regional Conference on February 2, 2013 in Washington, DC; the SAEM NorthEast Regional Conference on April 3, 2013 in Providence, RI; the SAEM National Conference on May 17, 2013 in Atlanta, GA; and the Council of Residency Directors Conference on March 7, 2013 in Denver, CO. This study was approved by the NYU Institutional Review Board.
RECEIVED: 17 May 2014; FINAL SUBMISSION RECEIVED: 30 October 2014; ACCEPTED: 21 December 2014 613
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axes for proper endotracheal tube placement, VL does not. VL devices incorporate a video camera on the undersurface of the blade that transmits an image to a video monitor, providing the operator and observers an indirect view of the glottic opening. Additionally, there are a number of distinct commercially available VL devices with unique technical features. All VL devices are not created equal. Many of the devices use different optics, blade angles, laryngoscope handles, and monitors. A full discussion of the differences between these devices is beyond the scope of this article and can be found in prior publications (8). These key design differences require the operator to employ different techniques to achieve an optimal glottic view (9). As a result, EMR programs must tailor airway training toward the VL devices available in their EDs. EMR programs also have a duty to train their residents to use DL, as VL may not always be present in the EDs they work in after graduation. The majority of emergency medicine graduates will practice in non-EMR EDs. Knowledge of the prevalence and type of VL in nonEMR EDs (in addition to EMR EDs) can aid in developing an appropriate airway-training curriculum. To our knowledge, no study has reported this information. MATERIALS AND METHODS Study Design This was a survey study. The survey design was selected because it was the most efficient way to discover the information in question. United States EMR programs and New York State non-EMR EDs were surveyed separately. EMR programs were identified from the list of Accreditation Council for Graduate Medical Education (ACGME)-accredited EMR programs across the country. To survey EMR programs, an Internet-based survey through SurveyMonkey (SurveyMonkey Inc., Palo Alto, CA) was distributed to EMR directors and assistant residency directors. Multiple sites within an EMR were accounted for and included only once in the study. An electronic link was sent via e-mail to all 158 ACGME-accredited EMR programs nationwide. The survey was open for completion from July 1, 2012 to October 1, 2012. Non-EMR EDs were defined as those in which no EM residents worked. To survey New York State nonacademic EDs, we generated a list of non-EMR EDs from New York State Department of Health data. EDs were then contacted directly by a study investigator for phone interviews. Non-EMR EDs were interviewed by phone because we were unable to find reliable e-mail addresses through which to contact these facilities. Phone interviews took place between August 24, 2013 and October 30, 2013.
Participation in this study was not incentivized or compensated. This study protocol was approved under exempt status by our institution’s institutional review board. Survey Instrument Two separate surveys were created by study investigators, which consisted of an assistant program director and three senior EM residents. The survey was designed to answer three distinct questions surrounding the use of VL in EMR and non-EMR EDs. The SurveyMonkey tool used for EMRs and the phone survey used for non-EMR EDs contained the same core questions. The non-EMR directed phone survey included one initial question to confirm the absence of an EMR training program at that hospital. The non-EMR ED survey is shown in Figure 1. The EMR survey included several supplemental questions to determine postgraduate year training levels and satellite locations receiving residents to prevent duplicates (Figure 2). The study was piloted among several EM physicians at our institution. Key Outcome Measures The primary purpose of this survey study was to identify the presence or absence and type of video laryngoscopes in EMR programs across the country and non-EMR EDs in New York State. The secondary endpoints of this study were to investigate the percentage of EMR programs with dedicated video laryngoscopy training curricula, and the presence of video laryngoscopy quality assurance (QA). Data Analysis A chi-squared test was used to determine whether the difference in presence of video laryngoscopy amongst EMR and non-EMR programs was significant. Statistical significance was defined as p < 0.05. Sample size calculation was not performed. RESULTS At the time of the study, there were 158 ACGMEaccredited EMR programs in the United States. All were surveyed, and 138 (87.3%) responded. A list of 132 non-EMR EDs was generated from the New York State Department of Health database. All were surveyed and 121 (91.7%) participated. Of the 138 EMR responders, 135 (97.8%) reported having some form of VL in their EDs. Among nonEMR ED responders, 102 of the 121 (84.3%) reported having VL. The difference in proportion of EMR vs. non-EMR EDs that have VL was c2 = 13 (p < 0.001).
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Figure 1. Non-emergency medicine residency video laryngoscopy survey. US = United States.
The GlidescopeÒ device (Verathon Medical, Bothell, WA) was present in 87.7% of EMR programs and 79.3% of non-EMR EDs. The Storz CMAC (Karl Storz, Tuttlingen, Germany) was present in 28.3% of EMR EDs but was not reported in any non-EMR EDs. The McGrath (Aircraft Medical, Edinburgh, UK) device was present in 6.7% of EMR programs and 3.3% of non-EMR EDs (Figure 3). Aside from Glidescope, Storz CMAC, and McGrath, other devices present in small numbers included: King Vision (Kingsystems, Noblesville, IN), Ambu-Pentax (Ambu, Ballerup, Denmark) RIFL (All Medical Devices, Willamston, MI), VividTrac (Vivid Medical Inc., Palo Alto, CA) and Glidescope Ranger (Verathon Medical). In two cases (1.5%), the responder in nonEMR EDs did not know the name of the VL device in use at their institution. Multiple VL devices were used to train residents in 25.2% of EMR programs, with 15.6% training on both Glidescope and Storz CMAC exclusively. Multiple devices were not present in nonEMR EDs. Of the 138 EMR ED responders, 132 answered the survey question regarding resident VL training; 57% of those who answered reported having a dedicated didactic curriculum for VL training in addition to clinical experience.
DISCUSSION Over the past decade, a diverse array of VL devices have emerged as potential alternatives to conventional DL. Their popularity is supported by data that suggest that the indirect view of the glottis provided by VL can improve visualization of the airway, increase successful intubation rates, and potentially increase first-pass intubations when compared to DL (10–13). This is of particular significance given recent data emphasizing the importance of first-pass success in preventing adverse events including oxygen desaturation, aspiration, and esophageal intubation (14). Laryngoscopy for intubation, whether direct or videoassisted, is a complex technical skill with a low success rate among novices. Studies show that practitioners require over 50 intubations prior to achieving a 90% success rate using DL (15). Similarly, formal training and practice is crucial to the success of VL. However, unlike with DL, the training and skill sets required are unique to the specific video laryngoscope being used. The Airtraq, for example, necessitates a specific set of nonintuitive maneuvers when repositioning, whereas the Glidescope requires a specific spatial manipulation when passing the endotracheal tube after an adequate view of the glottis is obtained (16). In this study, although the Glidescope
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Figure 2. Emergency medicine residency video laryngoscopy survey. US = United States.
was reported most frequently across both types of EDs, EMR EDs employed a wider variety of VL devices. In fact, although 30% of EMR EDs used the Storz CMAC, this device was not used in a single non-EMR ED in New York State. This information may be useful in guiding EMR programs in selection of specific VL devices for resident training. Regardless of the type of device, this study demonstrates widespread use of VL in academic EDs across the country, with 97.8% of responding EMR EDs reporting using VL. This represents a remarkable increase from the 43% rate of VL in EMR EDs reported in Massachu-
setts in 2009 (7). Our study did show, however, that adoption of VL technology is not uniform across academic and nonacademic EDs. We found significantly fewer nonEMR EDs in New York State use VL when compared to EMR EDs. This difference may be a result of multiple factors including cost, patient population, and acuity level. Alternatively, it may be a reflection of the evidence-to-practice gap, the concept that medical practice frequently lags behind available evidence (17). Given the stress on academics and research often found in EMR ED programs, it may seem intuitive that these programs tend toward earlier adoption of practices new to the
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Figure 3. Video laryngoscopy (VL) devices used by Emergency Medicine Residency (EMR) and non-EMR emergency departments (EDs).
literature. In practice, however, the evidence-to-practice gap has been demonstrated in both academic and community medical institutions (18). In previous studies, financial burden has been cited as a barrier to adoption of VL (7). The source of discrepancy between EMR and non-EMR groups in this study is uncertain. The Royal College of Anesthetists and the Difficult Airway Society concluded that insufficient education and training accounts for close to 50% of airway complications (19). Even when experienced anesthesiologists use the Glidescope, studies have reported significant adverse outcomes if those practitioners lack familiarity with the device (20). Additionally, studies show that although VL devices improve the view of the glottic opening, other technical challenges arise, including difficulty of tube passage, equipment failure, and obscuration of the screen (21,22). Such data are notable given the inconsistency of EMR VL curricula demonstrated in our study. Our study showed that just over half of EMR programs have a dedicated curriculum for VL training outside of on-shift clinical experience. Given the data highlighting the impact of insufficient DL training on airway complications, these numbers raise important questions. But specifically how this translates to VL training remains to be determined. Implications of these data are numerous. This study highlights the high prevalence of VL in EDs across the country, demonstrating a rising trend. This is supported by existing data on the potential of VL to improve successful intubation rates (10–13). However, this study also demonstrates a gap between VL prevalence in EMR and non-EMR EDs, arguing for continued focus on DL skills in training programs. The necessity for ongoing DL training is highlighted in an editorial by Ri-
chard Levitan, where he emphatically states that ‘‘we should not abandon teaching of direct laryngoscopy’’ (22). Levitan highlights a number of shortcomings with VL devices, including blood obscuring the fiber optics and loss of power source. Additionally, given the different types of VL devices used in EMR EDs vs. non-EMR EDs in New York State, these data can be used to help EMR programs select the most appropriate VL devices to use in resident training. Alternatively, the robust data on devices used in EMR EDs across the country could be used by local community EDs when selecting which VL devices to purchase. Additional studies are needed to further characterize VL training given to residents in EMR EDs. How much time residents spend on dedicated VL training, what that training entails, and the significance of dedicated training are questions that remain to be answered. Additionally, we did not collect data on formalized training for providers in non-EMR EDs. The presence or absence of postgraduate training at non-EMR sites could change curricular focus in EMR programs. Limitations We administered two types of surveys to the two groups in this study. EMR EDs received an online survey and non-EMR EDs answered a phone survey. It is possible that the quality of responses may have been better for the EMR programs, as these responders were able to fill out the survey in their own time and did not have to answer the question immediately on the phone. To address this and reduce error, when calling non-EMR EDs, data collectors attempted to get the most senior person available to answer the question.
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We did not collect data on specific details of VL training curricula or QA processes at EMR and nonEMR programs. The scope of educational curricula varies widely, including simulation sessions, cadaver training, airway workshops, one-on-one training, and more. Future studies investigating the details of VL education and QA processes at EMR and non-EMR programs would be interesting. Additionally, we did not collect data on the reason behind the lack of VL equipment at EMR and non-EMR EDs. Such data would be useful to identify potential barriers to incorporation of new technology. We did not perform a sample size calculation prior to beginning the study because we sought to survey the entire population. However, given the fact that the entire population sampled may not respond, this information could have been useful. Although we conducted a national survey of ACGMEaccredited EMR programs, we only surveyed non-EMR EDs in New York State. This discrepancy could have skewed the results of which devices are used, as VL device popularity may be regional. It is possible that non-EMR EDs in the rest of the country use a significant number of other devices not found in New York State. CONCLUSIONS Our data reveal that although there is a high penetration of VL devices in both EMR programs and non-EMR EDs, this group of devices is less common in the non-EMR EDs. Further studies should focus on determining the types of VL training programs offered in both EMR programs and non-EMR EDs. Assessment of the reasons (e.g., cost, patient volume) behind why both EMR and non-EMR programs do not have VL devices would also be important. Additionally, there should be more focus on evaluating QA efforts in both types of EDs. QA assessments may further guide the development of VL training curricula and highlight discrepancies in training vs. practice. REFERENCES 1. Aziz M, Brambrink A. The Storz C-MAC video laryngoscope: description of a new device, case report, and brief case series. J Clin Anesth 2011;23:149–52. 2. Benjamin FJ, Boon D, French RA. An evaluation of the GlideScope, a new video laryngoscope for difficult airways: a manikin study. Eur J Anaesthesiol 2006;23:517–21.
3. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anaesth 2003;50:611–3. 4. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anaesth 2005;52:191–8. 5. Hirabayashi Y. Airway scope: initial clinical experience with novice personnel. Can J Anaesth 2007;54:160–1. 6. Sakles JC, Rodgers R, Keim SM. Optical and video laryngoscopes for emergency airway management. Intern Emerg Med 2008;3:139–43. 7. Raja AS, Sullivan AF, Pallin DJ, Bohan JS, Camargo CA. Adoption of video laryngoscopy in Massachusetts emergency departments. J Emerg Med 2012;42:233–7. 8. Karalapilai D, Darvall J, Mandeville J, Ellard L, Graham J, Weinberg L. A review of video laryngoscopes relevant to the intensive care unit. Indian J Crit Care Med 2014;18:442–52. 9. Mosier J, Chiu S, Patanwala AE, Sakles JC. A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department. Ann Emerg Med 2013; 61:414–20. 10. Niforopoulou P, Pantazopoulos I, Demestiha T, Koudouna E, Xanthos T. Video laryngoscopes in the adult airway management: a topical review of the literature. Acta Anaesthesiol Scand 2010; 54:1056–61. 11. Lakticova V, Koenig SJ, Narasimhan M, Mayo PH. Video laryngoscopy is associated with increased first pass success and decreased rate of esophageal intubations during urgent endotracheal intubation in a medical intensive care unity when compared to direct laryngoscopy. J Intensive Care Med 2013;28:1–5. 12. Griesdale DEG, Liu D, McKinney J, Choi PT. Glidescope videolaryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth 2012; 59:41–52. 13. Sackles JC, Mosier JM, Chiu S, Keim S. Tracheal intubation in the emergency department: a comparison of GlidescopeÒ video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med 2012;42:400–5. 14. Sackles J, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20:71–8. 15. Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998;86:635–9. 16. Dhonneur G, Abdi W, Amathieu R, Ndoko S, Tual L. Optimising tracheal intubation success rate using the Airtraq laryngoscope. Anaesthesia 2009;64:315–9. 17. Graham ID, Logan J, Harrison MB, et al. Lost in translation: time for a map? J Contin Educ Health Prof 2006;26:13–24. 18. Eskigioglu C, Gagliardi AR, Fenech DS, et al. Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals. Can J Surg 2012;55:233–8. 19. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth 2011;106:617–31. 20. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth 2007;54:54–7. 21. Levitan RM, Heitz JW, Sweeny M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med 2011;57:240–7. 22. Levitan RM. Video laryngoscopy, regardless of blade shape, still requires a backup plan. Ann Emerg Med 2013;61:421–2.
EM Resident Clinical Hours Survey
ARTICLE SUMMARY 1. Why is this topic important? Given the wide range of video laryngoscopes available and the need for training specific to each device, it is preferable that residents receive training on devices they will encounter when practicing in the community. 2. What does this study attempt to show? This study attempts to compare the prevalence and type of video laryngoscopy devices in Emergency Medicine Residency (EMR) programs compared to non-EMR emergency departments (EDs) in New York State. 3. What are the key findings? This study reveals that although video laryngoscopy is present in the vast majority of EMR-EDs across the country, it is found less frequently in non-EMR EDs in New York State. The Glidescope is the device used most commonly in both settings. EMR EDs have additional devices not found in non-EMR centers. 4. How is patient care impacted? EMR programs should be aware of the discrepancy in presence and type of video laryngoscopy devices, as it may guide their airway training curricula.
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Education DO EMERGENCY MEDICINE RESIDENTS RECEIVE APPROPRIATE VIDEO LARYNGOSCOPY TRAINING? A SURVEY TO COMPARE THE UTILIZATION OF VIDEO LARYNGOSCOPY DEVICES IN EMERGENCY MEDICINE RESIDENCY PROGRAMS AND COMMUNITY EMERGENCY DEPARTMENTS Anand Kumar Swaminathan, MD, MPH, Rachel Berkowitz, MD, Annalee Baker, MD, and Meghan Spyres, MD Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital, New York, New York Reprint Address: Anand Kumar Swaminathan, MD, MPH, Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital, 462 1st Ave., OBV-A341, New York, NY 10016
, Abstract—Background: Video laryngoscopy (VL) has emerged as a critical tool in the ‘‘difficult airway’’ armamentarium of emergency physicians. The resultant increase in the types of available VL devices has made Emergency Medicine Residency (EMR) training in VL increasingly challenging. Additionally, the prevalence of VL devices in the community is unknown. Because Emergency Medicine (EM) residents go on to work in diverse settings, many in non-EMR emergency departments (EDs), it is preferable that they receive training on the airway modalities they will encounter in practice. Objective: To compare the prevalence and type of VL devices in EMR programs to nonEMR EDs. Methods: This was a survey study conducted from July 2012 to October 2012 of Accreditation Council for Graduate Medical Education-accredited, MD EMR programs in the United States and non-EMR EDs in New York State. A chi-squared test was performed to determine whether the difference in VL prevalence was significant. Results: There were 158 EMR programs and 132 non-EMR
EDs surveyed; 97.8% of EMR and 84.3% of non-EMR EDs reported having some form of VL in their departments. The difference in proportion of EMR vs. non-EMR EDs that have VL was c2 = 13 (p < 0.001). The GlidescopeÒ device (Verathon Medical, Bothell, WA) was present in 87.7% of EMR programs and 79.3% of non-EMR EDs. Conclusions: The majority of EMR programs trained residents in VL. The Glidescope device was used most frequently. Non-EMR EDs in New York State had a lower presence of VL devices, with the Glidescope device again being the most common. These results demonstrate that VL is pervasive in both practice environments. Ó 2015 Elsevier Inc. , Keywords—airway; video laryngoscopy; direct laryngoscopy; Glidescope; resident education
INTRODUCTION Direct laryngoscopy (DL) represents the conventional approach to intubation in the emergency department (ED). For many years, Emergency Medicine Residency (EMR) programs have focused resident airway training on developing DL skills. Over the last decade, various video laryngoscopy (VL) devices have emerged and are being used with increasing frequency in both EMR programs and non-EMR EDs (1–7). Whereas DL requires alignment of the pharyngeal, laryngeal, and tracheal
The work contained in this paper was presented at the Society of Academic Emergency Medicine (SAEM) Mid Atlantic Regional Conference on February 2, 2013 in Washington, DC; the SAEM NorthEast Regional Conference on April 3, 2013 in Providence, RI; the SAEM National Conference on May 17, 2013 in Atlanta, GA; and the Council of Residency Directors Conference on March 7, 2013 in Denver, CO. This study was approved by the NYU Institutional Review Board.
RECEIVED: 17 May 2014; FINAL SUBMISSION RECEIVED: 30 October 2014; ACCEPTED: 21 December 2014 613
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axes for proper endotracheal tube placement, VL does not. VL devices incorporate a video camera on the undersurface of the blade that transmits an image to a video monitor, providing the operator and observers an indirect view of the glottic opening. Additionally, there are a number of distinct commercially available VL devices with unique technical features. All VL devices are not created equal. Many of the devices use different optics, blade angles, laryngoscope handles, and monitors. A full discussion of the differences between these devices is beyond the scope of this article and can be found in prior publications (8). These key design differences require the operator to employ different techniques to achieve an optimal glottic view (9). As a result, EMR programs must tailor airway training toward the VL devices available in their EDs. EMR programs also have a duty to train their residents to use DL, as VL may not always be present in the EDs they work in after graduation. The majority of emergency medicine graduates will practice in non-EMR EDs. Knowledge of the prevalence and type of VL in nonEMR EDs (in addition to EMR EDs) can aid in developing an appropriate airway-training curriculum. To our knowledge, no study has reported this information. MATERIALS AND METHODS Study Design This was a survey study. The survey design was selected because it was the most efficient way to discover the information in question. United States EMR programs and New York State non-EMR EDs were surveyed separately. EMR programs were identified from the list of Accreditation Council for Graduate Medical Education (ACGME)-accredited EMR programs across the country. To survey EMR programs, an Internet-based survey through SurveyMonkey (SurveyMonkey Inc., Palo Alto, CA) was distributed to EMR directors and assistant residency directors. Multiple sites within an EMR were accounted for and included only once in the study. An electronic link was sent via e-mail to all 158 ACGME-accredited EMR programs nationwide. The survey was open for completion from July 1, 2012 to October 1, 2012. Non-EMR EDs were defined as those in which no EM residents worked. To survey New York State nonacademic EDs, we generated a list of non-EMR EDs from New York State Department of Health data. EDs were then contacted directly by a study investigator for phone interviews. Non-EMR EDs were interviewed by phone because we were unable to find reliable e-mail addresses through which to contact these facilities. Phone interviews took place between August 24, 2013 and October 30, 2013.
Participation in this study was not incentivized or compensated. This study protocol was approved under exempt status by our institution’s institutional review board. Survey Instrument Two separate surveys were created by study investigators, which consisted of an assistant program director and three senior EM residents. The survey was designed to answer three distinct questions surrounding the use of VL in EMR and non-EMR EDs. The SurveyMonkey tool used for EMRs and the phone survey used for non-EMR EDs contained the same core questions. The non-EMR directed phone survey included one initial question to confirm the absence of an EMR training program at that hospital. The non-EMR ED survey is shown in Figure 1. The EMR survey included several supplemental questions to determine postgraduate year training levels and satellite locations receiving residents to prevent duplicates (Figure 2). The study was piloted among several EM physicians at our institution. Key Outcome Measures The primary purpose of this survey study was to identify the presence or absence and type of video laryngoscopes in EMR programs across the country and non-EMR EDs in New York State. The secondary endpoints of this study were to investigate the percentage of EMR programs with dedicated video laryngoscopy training curricula, and the presence of video laryngoscopy quality assurance (QA). Data Analysis A chi-squared test was used to determine whether the difference in presence of video laryngoscopy amongst EMR and non-EMR programs was significant. Statistical significance was defined as p < 0.05. Sample size calculation was not performed. RESULTS At the time of the study, there were 158 ACGMEaccredited EMR programs in the United States. All were surveyed, and 138 (87.3%) responded. A list of 132 non-EMR EDs was generated from the New York State Department of Health database. All were surveyed and 121 (91.7%) participated. Of the 138 EMR responders, 135 (97.8%) reported having some form of VL in their EDs. Among nonEMR ED responders, 102 of the 121 (84.3%) reported having VL. The difference in proportion of EMR vs. non-EMR EDs that have VL was c2 = 13 (p < 0.001).
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Figure 1. Non-emergency medicine residency video laryngoscopy survey. US = United States.
The GlidescopeÒ device (Verathon Medical, Bothell, WA) was present in 87.7% of EMR programs and 79.3% of non-EMR EDs. The Storz CMAC (Karl Storz, Tuttlingen, Germany) was present in 28.3% of EMR EDs but was not reported in any non-EMR EDs. The McGrath (Aircraft Medical, Edinburgh, UK) device was present in 6.7% of EMR programs and 3.3% of non-EMR EDs (Figure 3). Aside from Glidescope, Storz CMAC, and McGrath, other devices present in small numbers included: King Vision (Kingsystems, Noblesville, IN), Ambu-Pentax (Ambu, Ballerup, Denmark) RIFL (All Medical Devices, Willamston, MI), VividTrac (Vivid Medical Inc., Palo Alto, CA) and Glidescope Ranger (Verathon Medical). In two cases (1.5%), the responder in nonEMR EDs did not know the name of the VL device in use at their institution. Multiple VL devices were used to train residents in 25.2% of EMR programs, with 15.6% training on both Glidescope and Storz CMAC exclusively. Multiple devices were not present in nonEMR EDs. Of the 138 EMR ED responders, 132 answered the survey question regarding resident VL training; 57% of those who answered reported having a dedicated didactic curriculum for VL training in addition to clinical experience.
DISCUSSION Over the past decade, a diverse array of VL devices have emerged as potential alternatives to conventional DL. Their popularity is supported by data that suggest that the indirect view of the glottis provided by VL can improve visualization of the airway, increase successful intubation rates, and potentially increase first-pass intubations when compared to DL (10–13). This is of particular significance given recent data emphasizing the importance of first-pass success in preventing adverse events including oxygen desaturation, aspiration, and esophageal intubation (14). Laryngoscopy for intubation, whether direct or videoassisted, is a complex technical skill with a low success rate among novices. Studies show that practitioners require over 50 intubations prior to achieving a 90% success rate using DL (15). Similarly, formal training and practice is crucial to the success of VL. However, unlike with DL, the training and skill sets required are unique to the specific video laryngoscope being used. The Airtraq, for example, necessitates a specific set of nonintuitive maneuvers when repositioning, whereas the Glidescope requires a specific spatial manipulation when passing the endotracheal tube after an adequate view of the glottis is obtained (16). In this study, although the Glidescope
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Figure 2. Emergency medicine residency video laryngoscopy survey. US = United States.
was reported most frequently across both types of EDs, EMR EDs employed a wider variety of VL devices. In fact, although 30% of EMR EDs used the Storz CMAC, this device was not used in a single non-EMR ED in New York State. This information may be useful in guiding EMR programs in selection of specific VL devices for resident training. Regardless of the type of device, this study demonstrates widespread use of VL in academic EDs across the country, with 97.8% of responding EMR EDs reporting using VL. This represents a remarkable increase from the 43% rate of VL in EMR EDs reported in Massachu-
setts in 2009 (7). Our study did show, however, that adoption of VL technology is not uniform across academic and nonacademic EDs. We found significantly fewer nonEMR EDs in New York State use VL when compared to EMR EDs. This difference may be a result of multiple factors including cost, patient population, and acuity level. Alternatively, it may be a reflection of the evidence-to-practice gap, the concept that medical practice frequently lags behind available evidence (17). Given the stress on academics and research often found in EMR ED programs, it may seem intuitive that these programs tend toward earlier adoption of practices new to the
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Figure 3. Video laryngoscopy (VL) devices used by Emergency Medicine Residency (EMR) and non-EMR emergency departments (EDs).
literature. In practice, however, the evidence-to-practice gap has been demonstrated in both academic and community medical institutions (18). In previous studies, financial burden has been cited as a barrier to adoption of VL (7). The source of discrepancy between EMR and non-EMR groups in this study is uncertain. The Royal College of Anesthetists and the Difficult Airway Society concluded that insufficient education and training accounts for close to 50% of airway complications (19). Even when experienced anesthesiologists use the Glidescope, studies have reported significant adverse outcomes if those practitioners lack familiarity with the device (20). Additionally, studies show that although VL devices improve the view of the glottic opening, other technical challenges arise, including difficulty of tube passage, equipment failure, and obscuration of the screen (21,22). Such data are notable given the inconsistency of EMR VL curricula demonstrated in our study. Our study showed that just over half of EMR programs have a dedicated curriculum for VL training outside of on-shift clinical experience. Given the data highlighting the impact of insufficient DL training on airway complications, these numbers raise important questions. But specifically how this translates to VL training remains to be determined. Implications of these data are numerous. This study highlights the high prevalence of VL in EDs across the country, demonstrating a rising trend. This is supported by existing data on the potential of VL to improve successful intubation rates (10–13). However, this study also demonstrates a gap between VL prevalence in EMR and non-EMR EDs, arguing for continued focus on DL skills in training programs. The necessity for ongoing DL training is highlighted in an editorial by Ri-
chard Levitan, where he emphatically states that ‘‘we should not abandon teaching of direct laryngoscopy’’ (22). Levitan highlights a number of shortcomings with VL devices, including blood obscuring the fiber optics and loss of power source. Additionally, given the different types of VL devices used in EMR EDs vs. non-EMR EDs in New York State, these data can be used to help EMR programs select the most appropriate VL devices to use in resident training. Alternatively, the robust data on devices used in EMR EDs across the country could be used by local community EDs when selecting which VL devices to purchase. Additional studies are needed to further characterize VL training given to residents in EMR EDs. How much time residents spend on dedicated VL training, what that training entails, and the significance of dedicated training are questions that remain to be answered. Additionally, we did not collect data on formalized training for providers in non-EMR EDs. The presence or absence of postgraduate training at non-EMR sites could change curricular focus in EMR programs. Limitations We administered two types of surveys to the two groups in this study. EMR EDs received an online survey and non-EMR EDs answered a phone survey. It is possible that the quality of responses may have been better for the EMR programs, as these responders were able to fill out the survey in their own time and did not have to answer the question immediately on the phone. To address this and reduce error, when calling non-EMR EDs, data collectors attempted to get the most senior person available to answer the question.
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We did not collect data on specific details of VL training curricula or QA processes at EMR and nonEMR programs. The scope of educational curricula varies widely, including simulation sessions, cadaver training, airway workshops, one-on-one training, and more. Future studies investigating the details of VL education and QA processes at EMR and non-EMR programs would be interesting. Additionally, we did not collect data on the reason behind the lack of VL equipment at EMR and non-EMR EDs. Such data would be useful to identify potential barriers to incorporation of new technology. We did not perform a sample size calculation prior to beginning the study because we sought to survey the entire population. However, given the fact that the entire population sampled may not respond, this information could have been useful. Although we conducted a national survey of ACGMEaccredited EMR programs, we only surveyed non-EMR EDs in New York State. This discrepancy could have skewed the results of which devices are used, as VL device popularity may be regional. It is possible that non-EMR EDs in the rest of the country use a significant number of other devices not found in New York State. CONCLUSIONS Our data reveal that although there is a high penetration of VL devices in both EMR programs and non-EMR EDs, this group of devices is less common in the non-EMR EDs. Further studies should focus on determining the types of VL training programs offered in both EMR programs and non-EMR EDs. Assessment of the reasons (e.g., cost, patient volume) behind why both EMR and non-EMR programs do not have VL devices would also be important. Additionally, there should be more focus on evaluating QA efforts in both types of EDs. QA assessments may further guide the development of VL training curricula and highlight discrepancies in training vs. practice. REFERENCES 1. Aziz M, Brambrink A. The Storz C-MAC video laryngoscope: description of a new device, case report, and brief case series. J Clin Anesth 2011;23:149–52. 2. Benjamin FJ, Boon D, French RA. An evaluation of the GlideScope, a new video laryngoscope for difficult airways: a manikin study. Eur J Anaesthesiol 2006;23:517–21.
3. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anaesth 2003;50:611–3. 4. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anaesth 2005;52:191–8. 5. Hirabayashi Y. Airway scope: initial clinical experience with novice personnel. Can J Anaesth 2007;54:160–1. 6. Sakles JC, Rodgers R, Keim SM. Optical and video laryngoscopes for emergency airway management. Intern Emerg Med 2008;3:139–43. 7. Raja AS, Sullivan AF, Pallin DJ, Bohan JS, Camargo CA. Adoption of video laryngoscopy in Massachusetts emergency departments. J Emerg Med 2012;42:233–7. 8. Karalapilai D, Darvall J, Mandeville J, Ellard L, Graham J, Weinberg L. A review of video laryngoscopes relevant to the intensive care unit. Indian J Crit Care Med 2014;18:442–52. 9. Mosier J, Chiu S, Patanwala AE, Sakles JC. A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department. Ann Emerg Med 2013; 61:414–20. 10. Niforopoulou P, Pantazopoulos I, Demestiha T, Koudouna E, Xanthos T. Video laryngoscopes in the adult airway management: a topical review of the literature. Acta Anaesthesiol Scand 2010; 54:1056–61. 11. Lakticova V, Koenig SJ, Narasimhan M, Mayo PH. Video laryngoscopy is associated with increased first pass success and decreased rate of esophageal intubations during urgent endotracheal intubation in a medical intensive care unity when compared to direct laryngoscopy. J Intensive Care Med 2013;28:1–5. 12. Griesdale DEG, Liu D, McKinney J, Choi PT. Glidescope videolaryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth 2012; 59:41–52. 13. Sackles JC, Mosier JM, Chiu S, Keim S. Tracheal intubation in the emergency department: a comparison of GlidescopeÒ video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med 2012;42:400–5. 14. Sackles J, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20:71–8. 15. Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998;86:635–9. 16. Dhonneur G, Abdi W, Amathieu R, Ndoko S, Tual L. Optimising tracheal intubation success rate using the Airtraq laryngoscope. Anaesthesia 2009;64:315–9. 17. Graham ID, Logan J, Harrison MB, et al. Lost in translation: time for a map? J Contin Educ Health Prof 2006;26:13–24. 18. Eskigioglu C, Gagliardi AR, Fenech DS, et al. Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals. Can J Surg 2012;55:233–8. 19. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth 2011;106:617–31. 20. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth 2007;54:54–7. 21. Levitan RM, Heitz JW, Sweeny M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med 2011;57:240–7. 22. Levitan RM. Video laryngoscopy, regardless of blade shape, still requires a backup plan. Ann Emerg Med 2013;61:421–2.
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ARTICLE SUMMARY 1. Why is this topic important? Given the wide range of video laryngoscopes available and the need for training specific to each device, it is preferable that residents receive training on devices they will encounter when practicing in the community. 2. What does this study attempt to show? This study attempts to compare the prevalence and type of video laryngoscopy devices in Emergency Medicine Residency (EMR) programs compared to non-EMR emergency departments (EDs) in New York State. 3. What are the key findings? This study reveals that although video laryngoscopy is present in the vast majority of EMR-EDs across the country, it is found less frequently in non-EMR EDs in New York State. The Glidescope is the device used most commonly in both settings. EMR EDs have additional devices not found in non-EMR centers. 4. How is patient care impacted? EMR programs should be aware of the discrepancy in presence and type of video laryngoscopy devices, as it may guide their airway training curricula.
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