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Three Part Question

For [paramedics], [what education and training are required] to [gain initial competence in endotracheal intubation]?

Clinical Scenario

You attend a 60 year old male in cardiac arrest. A double crewed ambulance with a student observer and a rapid response vehicle are already on scene. The patient has ongoing CPR and with effective ALS you regain a pulse. At this point the decision is made to intubate the patient to secure their airway for transport. During the debrief intubation is discussed and the student asks about the training the paramedics at the scene received. There is considerable variation in the training received by the paramedics and the training the student paramedic is undergoing at present. This sets you thinking about how paramedics actually learn to intubate.

Search Strategy

NICE Evidence Healthcare Database search using AMED (Ovid) 1985 to Nov 2014, BNI (Ovid) 1982 to Nov 2014, CINAHL (EBSCO) 1981 to Nov 2014, Embase (Ovid) 1980 to Nov 2014, HMIC: DH-Data and Kings Fund (Ovid) 1979 to Nov 2014, Medline (Ovid) 1946 to Nov 2014 and Psycinfo (Ovid) 1806 to Nov 2014.
The search terms used were ((endotracheal intubation OR eti OR intubation OR tracheal intubation OR entubation) AND (prehospital OR pre-hospital OR paramedic* OR ambulance* OR ems OR emt OR (emergency AND services) OR (emergency AND medical AND service*) OR (emergency AND technician*) OR (emergency AND practitioner)) AND (educat* OR learn* OR train* OR competenc* OR attain* OR practice OR capabil* OR capacity OR expert* OR skill* OR proficien* OR suitab*))

Search Outcome

163 papers were considered of which 13 were included. 7 additional papers were identified in the references and through author knowledge.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pepe et al 2015 USA	N/a	Literature review	Unique training challenges described	Quality, orientation and type of experience initial training key determinant of success	Critical review of prehospital intubation as a wider topic with training a small element.
				Difference between pre-hospital and in-hospital environment described
				Value of street wise, highly experienced trainers and supervisors
Sergeev et al 2012 Israel	98 physicians and 85 paramedics from the Israeli military	Anonymous structured questionnaire	Paramedic training described	Paramedics have higher exposure to intubation during training (51 vs 32 supervised and 14 vs 2.8 unsupervised)	Study includes physicians as well as paramedics. Data based on self-reporting via questionnaire. Intubation one skill amongst many studied.
			Training modality and self-confidence related	Unsupervised > supervised > mannequin training
			Plateau in self-confidence described for training modalities	30 mannequin intubations necessary to reach plateau
Warner et al 2010 USA	56 paramedic students over 3 years	Secondary analysis of prospectively collected data	Paramedic intubation training described	Mannequin training with instructors and lectures followed by in-hospital practical experience. Once 5 succesful intubations performed in-hospital student then allowed to intubate under supervision in the field.	RSI drugs used in majority of pre-hospital intubations. Use of self-reporting for data collection.
			Location and number of intubations described	Median 29 intubations over 3 years. around 1/3rd in pre-hospital setting.
			Learning curve for intubation described.	Plateau described above 15 intubations for overall success but no plateau up to 20 intubations for pre-hospital first pass success.
Deakin et al 2010 UK	N/a	Expert opinion	Comment on IHCD standards which required 25 intubations (including 5 unassisted) during hospital based training.	Lack of evidence for 25 intubations.	Expert opinion
			Comment on intubation as a skill practiced by all paramedics.	Suggestion that intubation should be a skill only used by a subset of paramedics.
			Comment on availability and method of intubation training.	Description of declining training opportunities but suggestion that basic skills and knowledgecan be gained and practiced on a mannequin
Deakin et al 2009 UK	15 UK Ambulance trusts	Survey of initial and ongoing intubation training	Initial training required for intubation by each trust.	5-25 intubations in theatre. Some trusts accepting lesser numbers if paramedic judged competent.	Survey based on old method of paramedic training which has larely been replaced now.
McCall et al 2008 Australia	58 paramedics with advanced airway management skills	Prospective observational study of intubating laryngeal mask	Training required to perform intubation.	Succesful completion of respiratory theory paper plus 20 supervised intubations in hospital.	Brief mention of intubation training as not main focus of paper.
Thomas et al 2007 USA	14 paramedics and 6 EMS director physicians	Focus groups and interviews	Adequacy of paramedic intubation training.	"Bare minimum" standards and lack of uniformity in education and mentoring. Lack of practice opportunities in theatres.	Study of wider subject of challenge in out-of-hospital intubation. Select sample of paramedics and physicians.
Wang and Katz 2007 USA	N/a	Application of 'Skills-Rules-Knowledge' conceptual framework to intubation	Recommendations around intubation training.	Recommend training intubation as part of wider airway management approach.	Application of theoretical framework.
				Support use of simulation as a supplement to live experience.
Johnston et al 2006 USA	161 directors of paramedic training programs	Anonymous structured questionnaire	Description of operating room training.	Median 17-32 hours access operating room per student.	Focus of study limited to paramedic student access to operating rooms and only included accredited training programs.
				Median 6-10 intubation attempts per student.
				Increasing competition for access to operating rooms.
Wang and Yealy 2006 USA	N/a	Review of recent literature on paramedic intubation	Paramedic training requirements compared to other intubating professions.	Disparity between paramedics (5) and other intuabting professions requirements (35-200) in terms of number of intubations required.	None
			Paramedic student intubation attempts described.	Median of 7 intubation attempts whereas 15-20 necessary for baseline proficiency.
			Different training strategies described.	Brief description of varying training strategies including mannequin, animal, operating room, simulator and cadaveric.
Hall et al 2005 Canada	36 paramedic students with no prior intubation experience	Prospective randomised controlled trial	Comparison of 10 hours simulation versus 15 operating room intubations.	Simulator training was found to be equivalent to operating room training in terms of success and complication rate.	Students all had 20 hours didactic and video training plus 10 hours mannequin training prior to study. Testing carried out in operating room.
Wang et al 2005 USA	60 paramedic training programs with 802 paramedic students	Secondary analysis of longitudinal, multi-centre data	Reports of intubation success on live patients used to model learning curve	9.5 mean and 7 median intubations per student.	Self-reported data used but mannequin and simulator experience excluded. Majority of intubations were in opearting rooms. Number of intubations described but no accounting for quality or difficulty of intubation.
				Operating room described as ideal training.
				Pre-hospital and ICU intubation provides greatest learning benefits but starts with lower success rate,
				Suggestion that paramedic students require >15-25 live intubations to acheive >90% success.
Pratt and Hirshberg 2005 USA	4 EMT-Basics who successfully completed an intubation training program	Observational study	Training undertaken by participants described	14 hours of didactic learning, 20 hours of practical sessions and 10 successful live intubations.	Small number of participants selected based on experience, interest and ability to complete the project.
			Ongoing training by participants described.	Refresher training every 90 days.
			Success rate of participant intubation in respiratory and cardiac arrest.	94% success rate in 32 attempts.
Mulcaster et al 2003 Canada	20 non-anaesthesia trainees including 12 student paramedics	Longitudinal study of intubation under training conditions in the operating room	Initial training described	>20 successful mannequin intubations after training by a staff anaesthetist	Only uncomplicated airways used with drug assistance in the operating room setting. Study sample includes mixed population.
			Statistical modelling of necessary intubations to perform a	47 intubations necessary to have a 90% probability of a good intubation
Owen and Plummer 2002 Australia	115 healthcare professionals including <20 paramedics	Description of intubation teaching program	Teaching methods described	Logical progression using video, demonstration and practice on different airway models with feedback	Unknown number of paramedics described as having "extensive skills in airway management". Findings limited to simulation as no live patients intubated.
			Varying group sizes tested	2 students per group described as most effective
			Optimal session length described	75-90 minute sessions optimal
			Paramedic learning curve described	Rapid learning curve approaching 100% success after 6 attempts
Levitan et al 2001 USA	36 paramedic trainees using an instructional video in addition to normal teaching	Cohort comparison against historical data	Paramedic training described	42 hours didactic teaching including mannequin practice. Intervention group watched a 26 minute instructional video 3 times.	Historical cohort used as comparison. Lower mean attempts by video group (2.8 vs 7.0). Intubations reported all based in operating room.
			Success rate with additional video instruction compared to normal instruction	Video group 88.1% mean succes rate vs normal group 46.7% mean success rate
Plummer and Owen 2001 Australia	13 paramedic trainees in a cohort of 100 subjects	Development of a statistical model describing the process of learning intubation	Description of best fitting model	Logarithmic model has best fit with observed data. Rapid early gains leading to a plateau after around 10 attempts	Purely based on mannequin / model intubation. Low frequency of >15 intubations. Unknown previous intubation experience of paramedics. Paramedics only 13% of population.
			Comment on use of multiple different airway trainers	Changing trainers decreases success rate but promotes retention and transferability of skill
			Comment on value of successful versus unsuccessful practice	Trainees learn more from successful than unsuccessful intubations
Stratton et al 1991 USA	125 paramedic students randomised to mannequin only or mannequin plus cadaver training in intubation	Prospective evaluation comparing intubation success rates after randomised training	Clear description of training program	60 minute didactic lecture, 5x20 minute supervised practice sessions on mannequin with distractors. Open access to mannequins for self-guided practice. Cadaver group completed 3 physician supervised cadaver intubations	Small number of actual intubations. Participants were mostly firefighter paramedics so different model to UK practice. Self reported data with additional monitoring.
			Success rates of both groups described	Mannequin only 82% vs mannequin plus cadaver 83% mean individual success rate
			Complication rates of both groups described	Similar numbers of complications reported in both groups
Stewart et al 1984 USA	130 advanced life support technicians	Prospective study comparing training methods used introducing intubation as a new skill	Varying combinations of training described	Groups 1 and 2 had lectures, demonstrations, mannequin use, animal intubation and operating room experience. Group 3 had no operating room experience. Group 4 had only classroom instruction and mannequin practice. No significant difference in success rates based on training method were found.	Study conducted 30+ years ago. Study limited to narrow selection of patients including cardiac arrest and deep coma
			Success rates described over time	Overall 90% success rate. Groups 3 and 4 had lower initial success rates but then all groups acheived 94.5% success which was attributed to experience.
Toda, Toda and Arakawa 2013 Japan	32 paramedics being trained in intubation	Observational study of the introduction of intubation as a new skill for Japanese paramedics	Clear description of training undertaken	Standardised lecture, video learning, mannequin practice and 30 live intubations.	All intubations performed in the operating room on healthy patients with anaesthetic drugs. Maximum of 30 intubations by any participant.
			Intubation learning curve modeled	30 live intubations leads to 87% success rate. Little benefit from less than 13 intubations shown.
			Prevalance of complications studied	High rate of complications amongst novice intubators which decreases with experience

Comment(s)

It appears from the papers reviewed that Endotracheal Intubation (ETI) for paramedics should be included as part of the wider subject of airway management. Training specific to ETI needs to cover underpinning knowledge and supporting information, learning the basic skills with practice in a safe environment using simulation then advancing to exposure to patients. A logbook should be kept during the education program to promote reflection and prepare the paramedic for independent practice where keeping a log of all ETIs is best practice. Simulation seems a viable, effective and cost efficient method of learning and practicing the necessary skills and eliminates the need for animal or cadaver practice which may be unethical, expensive and difficult to arrange. The use of multimedia, such as recording of real ETIs, should be used to enhance and support the learning experience. All training should aim towards preparing the practitioner for the pre-hospital environment. High fidelity simulation would aim to replicate the prehospital environment by varying scenarios and situations and incorporating distractors. Operating theatres have historically provided the safe learning environment for paramedics. However, due to the increasing numbers of paramedic students, the decreasing use of ETI in operating theatres and competition from other medical professions for the limited opportunities to undertake ETI this may not be a sustainable way of educating paramedics. The total number of ETIs needed to achieve initial competence is difficult to quantify but appears to be above the 25 ETIs specified by the UK Institute of Health Care Development (IHCD) and its predecessors. This number will vary from individual to individual and depends on many factors including confidence, level of fidelity and methods of training, exposure to pre-hospital ETI and supervision. Supervision is very important, both during initial training and for support once working in the pre-hospital environment.

Clinical Bottom Line

From the evidence reviewed paramedics learning ETI require education and a training program that covers the range of airway management techniques up to and including ETI. Initial competence requires underpinning knowledge and supporting information, practice on manikins/simulators and a minimum of 25 to 35 in hospital or pre-hospital ETIs, some of which may be gained using high fidelity simulators, with supervision by clinicians with pre-hospital ETI experience.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Pepe PE, Roppolo LP, Fowler RL. Prehospital endotracheal intubation: elemental or detrimental? Critical Care 2015; 1-7
2. Sergeev I, Lipsky AM, Ganor O, Lending G, Abebe-Campino G, Morose A, Katzenell U, Ash N, Glassberg E. Training Modalities and Self-Confidence Building in Performance of Life-Saving Procedures Military Medicine 2012; 901-906
3. Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR. Paramedic Training for Proficient Prehospital Endotracheal Intubation Prehospital Emergency Care 2010: 103-108
4. Deakin CD, Clarke T, Nolan J, Zideman DA, Gwinnutt C, Moore F, Ward M, Keeble C, Blancke W. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal colleges Ambulance Liaison committee Airway Working Group, June 2008 Emergency Medicine Journal 2010; 226-233
5. Deakin CD, King P, Thompson F. Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills? Emergency Medicine Journal 2009: 888-891
6. McCall MJ, Reeves M, Skinner M, Ginifer C, Myles P, Dalwood N. Paramedic Tracheal Intubation Using the Intubating Laryngeal Mask Airway Prehospital Emergency Care 2008: 30-34
7. Thomas JB, Abo BN, Wang HE. Paramedic Perceptions of Challenges in Out-of-Hospital Endotracheal Intubation Prehospital Emergency Care 2007; 219-223
8. Wang HE and Katz S. Cognitive Control and Prehospital Endotracheal Intubation Prehospital Emergency Care 2007: 234-239
9. Johnston BD, Seitz SR, Wang HE. Limited Opportunities for Paramedic Student Endotracheal Intubation Training in the Operating Room Academic Emergency Medicine 2006: 1051-1055
10. Wang HE and Yealy DM. Out-of-Hospital Endotracheal Intuabtion: Where Are We? Annals of Emergency Medicine 2006; 532-541
11. Hall RE, Plant JR, Bands CJ, Wall AR, Kang J, Hall CA. Human Patient Simulation Is Effective for Teaching Paramedic Students Endotrachel Intubation Academic Emergency Medicine 2005; 850-855
12. Wang HE, Seitz SR, Hostler D, Yealy DM. Defining the "Learning Curve" for Paramedic Student Endotracheal Intubation Prehospital Emergency Care 2005; 15-162
13. Pratt JC and Hirshberg AJ. Endotracheal Tube Placement by EMT-Basics in a Rural EMS System Prehospital Emergency Care 2005; 172-175
14. Mulcaster JT, Mills J, Hung OR, MacQuarrie K, Law SJ, Pytka S, Imrie D, Field C. Laryngoscopic Intubation: Learning and Performance Anaesthesiology 2003; 23-27
15. Owen H and Plummer JL. Improving learning of a clinical skill: the first year's experience of teaching endotracheal intubation in a clinical simulation facility Medical Education 2002; 635-642
16. Levitan RM, Goldman TS, Bryan DA, Shofer F, Herlich A. Training with video imaging improves the initial intubation success rates of paramedic trainees in an operating room setting Annals of Emergency Medicine 2001; 46-50
17. Plummer JL and Owen H. Learning Endotracheal Intubation in a Clinical Skills Learning Centre: A Quantative Study Anaesthesia and Analgesia 2001; 656-662
18. Stratton SJ, Kane G, Gunter CS, Wheeler NC, Abelson-Ward C, Reich E, Pratt FD, Ogata G, Gallagher C. Prospective Study of Manikin-only Versus Manikin and Human Subject Endotracheal Intubation Training of Paramedics Annals of Emergency Medicine 1991; 1314-1318
19. Stewart RD, Paris PM, Winter PM, Pelton GH, Cannon GM. Field Endotracheal Intubation by Paramedical Personnel: Success Rates and Complications Chest 1984; 341-345
20. Toda J, Toda AA, Arakawa J. Learning curve for paramedic endotracheal intubation and complications International Journal of Emergency Medicine 2013;6:38