Defining Procedural Competency in Emergency Medicine

As originally published in EM Resident.

A recent retrospective review analyzing a group of academic, community and free-standing EDs published in JACEP Open showed that emergency physicians performed a median number of three intubations and zero chest tube thoracostomies, CVC placements, and lumbar punctures per year.[1] In addition, a quarter of the emergency physicians in the study performed zero intubations.

This as well as other recently published studies that look at the frequency with which emergency physicians perform procedures [2] raise the question of how often is enough to maintain procedural competence. To dive a bit deeper into this issue, let’s focus on what may be the most critical and high-risk procedures performed by emergency medicine clinicians, endotracheal intubation.

Acquisition

Before discussing skill maintenance, it would be prudent to take a look at skill acquisition. The Accreditation Council for Graduate Medical Education (ACGME) requires residents to perform a minimum of 35 endotracheal intubations prior to graduation.[3] Where does the ACGME get this number? Evidently not from the literature. The studies defining a learning curve for direct laryngoscopy are heterogeneous in their methods, settings, and definition of “competence.”  A systematic review performed in 2015 said that at least 50 intubations are needed to achieve a 90% success rate within two attempts in elective circumstances.[4] An often-cited study by Konrad et al in 1999 showed anesthesiology residents needed on average 57 intubations to achieve a 90% success rate within two attempts, but 18% of residents still required assistance from an attending after 80 attempts.[5] Bernhard et al showed that anesthesiology residents showed that first pass success steadily increased from 67% within the first 25 intubations to 83% after 200 intubations.[6]

Taken together, we can conclude that 50 intubations is the bare minimum for “competence” at intubation and clinicians will still see improvements far beyond that. It is also likely that this number is significantly higher for intubation outside the OR, where hemodynamic instability, respiratory failure, and airway contamination can all complicate matters. So how does the experience of EM residents compare? A national survey performed in 1999 of EM residencies showed that residents perform an average of 75 intubations during residency with a range from 13 to 180.[7] The most recent data we have was performed in a single center with a 3-year residency where residents performed an average of 28.91 intubations a year.[8]

We can therefore conclude that the average emergency physician won’t hit competence  with intubation until towards the end of residency. What’s more, with some performing as few as 13 over a 3 or 4 year period, there are likely others who may never truly master this important skill during their training.

The matter is further complicated by the introduction of video laryngoscopy, which is increasingly utilized in emergency medicine,[9] and is now the most common method of intubation in some centers.[10] All the studies mentioned that have looked at the learning curve for intubation utilized direct laryngoscopy. While Macintosh or “standard-geometry” video laryngoscopes overlap in technique with direct laryngoscopy and can themselves be used to obtain a direct view of the glottis, hyperangulated laryngoscopes require a separate technique and have, presumably, a distinct learning curve towards competence. The more emergency physicians rely on these devices, the less they progress along the steep but prolonged learning curve of direct laryngoscopy.

Maintenance

Now let’s turn towards skill maintenance. There is little in the literature that addresses this, but one study did look at this question among academic emergency medicine attendings. It found that performing 3 or supervising 5 intubations per year correlated with “proficient performance.”[11] However, there are several limitations to this study. It utilized airway manikins in a simulated setting and defined competence according to a checklist of actions as well as a psychomotor adeptness rating scale from 0-10. Several studies have shown that airway manikins are not as “high-fidelity” as their manufacturers would leave us to believe,[12,13] and many would agree that there is a wide gap between intubating a manikin in a simulation center as compared to a real patient under less than ideal circumstances. How these findings translate to clinical practice is still up for debate.

In Conclusion

Overall, there is much lacking in how we address the issue of acquisition and maintenance of procedural competency in emergency medicine. There is sure to be more discussion and research into these questions, but perhaps it is all much ado about nothing. We are the “jack of all trades and master of none (except resuscitation).” Emergency medicine is a dynamic and broad field which requires improvisation, creativity, and constant adaptation. It is the potential of lifelong learning that attracted many of us to our specialty, and the striving to always improve that keeps bringing us back. In a certain way, the ideal emergency physician is the one who has mastered the art of being “perfectly imperfect.” While I may never be a perfect proceduralist, I will also never be a perfect historian, communicator, educator, patient advocate or clinician. Perfection, however, is the enemy of the good. At the end of the day, I’m happy with excellence, not perfection, and progression, not stagnation. That’s why I love what I do, and that’s why we as emergency physicians have the best job in the world.

References:

1. Simon E, Smalley C, Meldon S et al. Procedural frequency: Results from 18 academic, community and freestanding emergency departments. J Am Coll Emerg Physicians Open. 2020. doi:10.1002/emp2.12238
2. Carlson JN, Zocchi M, Marsh K, et al. Procedural experience with intubation: results from a National emergency medicine group. Ann Emerg Med. 2019;74(6):786-794.
3. Review Committee for Emergency Medicine. Emergency Medicine Defined Key Index Procedure Minimums. acgme.org. https://www.acgme.org/Portals/0/PFAssets/ProgramResources/EM_Key_Index_Procedure_Minimums_103117.pdf?ver=2017-11-10-130003-693. Published 2017. Accessed December 10, 2020. 
4. Buis ML, Maissan IM, Hoeks SE, Klimek M, Stolker RJ. Defining the learning curve for endotracheal intubation using direct laryngoscopy: A systematic review. Resuscitation. 2016;99:63-71. doi:10.1016/j.resuscitation.2015.11.005
5. Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures?. Anesth Analg. 1998;86(3):635-639. doi:10.1097/00000539-199803000-00037
6. Bernhard M, Mohr S, Weigand MA, Martin E, Walther A. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand. 2012;56(2):164-171. doi:10.1111/j.1399-6576.2011.02547.x
7. Hayden SR, Panacek EA. Procedural competency in emergency medicine: the current range of resident experience. Acad Emerg Med. 1999;6(7):728–35.
8. Bucher JT, Bryczkowski C, Wei G, et al. Procedure rates performed by emergency medicine residents: a retrospective review. Int J Emerg Med. 2018;11(1):7. Published 2018 Feb 14. doi:10.1186/s12245-018-0167-x
9. Brown 3rd CA, Bair AE, Pallin DJ, Walls RM, NI Investigators. Techniques, success, and adverse events of emergency department adultintubations.Ann Emerg Med 2015;65:363–70, e1.
10. April MD, Schauer SG, Brown Rd CA, Ng PC, Fernandez J, Fantegrossi AE, Maddry JK, Summers S, Sessions DJ, Barnwell RM, Antonacci M. A 12-month descriptive analysis of emergency intubations at Brooke Army Medical Center: a National Emergency Airway Registry study. US Army Med Dep J. 2017 Oct-Dec;(3-17):98-104. PMID: 29214627.
11. Gillett B, Saloum D, Aghera A, Marshall JP. Skill Proficiency is Predicted by Intubation Frequency of Emergency Medicine Attending Physicians. West J Emerg Med. 2019;20(4):601-609. doi:10.5811/westjem.2019.6.42946
12. Schebesta K, Hüpfl M, Rössler B, Ringl H, Müller MP, Kimberger O. Degrees of reality: airway anatomy of high-fidelity human patient simulators and airway trainers. Anesthesiology. 2012;116(6):1204-1209. doi:10.1097/ALN.0b013e318254cf41
13. Schebesta K, Hüpfl M, Ringl H, Machata AM, Chiari A, Kimberger O. A comparison of paediatric airway anatomy with the SimBaby high-fidelity patient simulator. Resuscitation. 2011;82(4):468-472. doi:10.1016/j.resuscitation.2010.12.001