Effect of a Training Program for Nonanesthesiologists on Out-of-Operating Room Endotracheal Intubation

Background: Outside of the operating room airway management (OOORAM) poses unique challenges and is associated with increased complications when compared with routine operative airway management. Approaches to airway management between healthcare systems is variable in terms of operator training and expertise and may be associated with adverse patient outcomes. In response to this, the Veterans Health Administration created a mandatory standardized OOORAM training program in 2013. Objective: We sought to evaluate the effect that introduction of the OOORAM training program had on first-pass laryngoscopy success. Methods: This is a retrospective cross-sectional study of out-of-operating room endotracheal intubations performed at a single academically affiliated tertiary care center from June 2008 through June 2018. The study interval is 5 years before and after the introduction of the OOORAM program in 2013. Data were extracted from standardized intubation notes for all patients undergoing out-of-operating room intubation from the electronic medical system. The primary outcome was first-pass laryngoscopy success, defined as successful intubation with a single insertion of the laryngoscope. A secondary analysis restricted the cohort to experienced providers to evaluate the effect of OOORAM training in this group. Results: The overall rate of successful laryngoscopy improved from 73.0% to 78.2% (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.06-1.75) after the introduction of the OOORAM program. Similarly, overall first-pass intubation success rates showed a trend toward improvement, rising from a baseline of 77.2-83.1%, but did not reach statistical significance (OR, 1.17; 95% CI, 0.88-1.55). The rate of esophageal intubation decreased after OOORAM training from 9.6% to 5.1% (P = 0.001). The use of video laryngoscopy was not associated with a significant difference in first-pass laryngoscopy (P = 0.586) or first-pass intubation (P = 0.375). There was no improvement in first-pass laryngoscopy or intubation success after introduction of the training program in the experienced provider cohort. Conclusion: We have shown that a limited duration, facility-wide training intervention OOORAM is associated with improved first-pass laryngoscopy success and reduced rates of esophageal intubation.