Impact of simulation-based training on difficult airway management among anesthesia trainees and nurses as real team

Abstract

Background and Aims:

Difficult airway management is a critical skill requiring quick decision-making and effective team coordination. However, healthcare workers often lack real-life experience due to rarity of such instances. The aim of this study was to evaluate the effectiveness of simulation-based training for difficult airway management on real teams.

Material and Methods:

A prospective quasi-experimental study was conducted with 24 participants divided into six teams, each comprising three resident doctors and one staff nurse. An initial baseline simulation (S0) was conducted, followed by didactic sessions and skill training. Subsequent simulation sessions were carried out two weeks after the skill training (S1) and again six months later (S2). The primary objective was to evaluate the improvement in skills of real teams by comparing checklist scores. Simultaneously, retention of these skills and behaviour changes in real-world clinical practice were also assessed. Data were analyzed using descriptive and inferential statistics.

Results:

Notable improvement in team performance was observed during post-skill training simulations compared to baseline, as demonstrated by a significant increase in technical and non-technical skill scores [mean (SD): 26.7 (6.3) at S0 to 67.8 (7.3) at S1; P < 0.001]. Critical airway management skills, including time to call for help, deliberation time, and cricothyroidotomy time, also showed significant improvement. Skill retention was observed at the six-month simulation session [mean (SD) at S2 66.8 (4.1); P = 0.7]. Participants and observers reported increased confidence and situational awareness in real-world settings.

Conclusions:

This single-institute multi-professional team training resulted in significant improvement and retention of technical and non-technical skills of real teams in managing difficult airway.

Introduction

Difficult airway management is essential for anesthesiologists and operating theatre (OT) staff. Although the incidence of unanticipated difficult airways is reported to be as low as 0.003% in the OT, the consequences from “cannot intubate, cannot oxygenate” (CICO) situations may be severe risks of hypoxic brain injury or mortality.[1,2] According to closed claim data from the United States, 90% of such incidents are considered preventable.[3] The National Airway Project (NAP4) indicates that up to 40% of these incidents relate to human factors, highlighting the need for structured team training.[4] At our institution, 12 cases of unanticipated difficult airways occurred in the previous year, with three escalating to CICO situations.

The Difficult Airway Society (DAS) recommends surgical cricothyroidotomy (SCT) as the emergency procedure for CICO situations.[5] However, due to the rarity of such events, anesthesia trainees and OT staff often lack confidence in SCT.[6,7] Simulation-based education offers a practical approach for airway management in a controlled environment, with studies showing it enhances learners’ skills and confidence in difficult airway scenarios.[8,9,10] However, there is limited evidence on the role of simulation-based inter-professional team training in building proficiency and confidence among resident doctors and perioperative staff nurses to follow a protocolized approach for managing difficult airways.

This prospective quasi-experimental study evaluated a multi-professional, simulation-based team training for difficult airway management at a single institution. The aim was to assess the effectiveness of this training in improving technical and non-technical skills for a protocolized approach to airway management as a real team, hypothesizing significant improvement and skill retention six months post-intervention.

Primary objective was to evaluate the improvement of team-based technical and non-technical skills following the simulation-based training. Secondary objectives included evaluating six-month skill retention and assessing changes in clinical behavior and practice in real-world airway management.

Material and Methods

This prospective quasi-experimental study, conducted from January 2024 to June 2024, examined the impact of an educational intervention in airway management using simulation-based training. After obtaining Institutional Ethics Committee approval and Clinical Trials Registry-India (CTRI) registration, we included anesthesiology residents and staff nurses who worked as a perioperative team for at least 12 months. An informed consent and a confidentiality agreement was obtained from all eligible participants. The study followed reporting guidelines for healthcare simulation research, an extension of the strengthening the reporting of observational studies in epidemiology (STROBE) Statements.[11]

To ensure comprehensive coverage of the topic and a uniform knowledge, a learning module was prepared, covering airway management guidelines, video resources, and DAS cognitive aids. The simulation took place in a skill laboratory set up to resemble an OT and were run on two ARES advanced patient simulators (CAE Healthcare, Sarasota, FL, USA) with Maestro software technology. Other equipment included patient monitors, anesthesia workstations, difficult airway carts, drug carts, and a defibrillator.

Simulation script was developed by two Pediatric Simulation Training and Research Society-(https://pedistarsindia.com/)[12] trained facilitators using the simulation scenarios quality instrument (SSQI).[13] The scenario depicted a difficult airway in a patient undergoing lumbar laminectomy, progressing to a CICO situation requiring SCT. The duration of pre-brief, scenario run, and learner-centered debriefing were 5–6 minutes, 10–12 minutes, and 15-–20 minutes, respectively, for each immersive simulation session. To simulate desaturation, the SpO2 values were programmed to drop by 3% every 5 seconds if oxygen was not delivered, reaching 90% in 20 seconds. An SpO2 value of less than 90% was considered desaturation.[14] Adequate ventilation was defined as achieving at least two effective breaths, as shown by an EtCO2 curve on the monitor. This curve was digitally simulated and controlled by the instructor according to the scenario conditions. Pharyngeal obstruction was manually created to simulate a “cannot intubate” situation, and lung stiffness was adjusted using software with successive intubation attempts to simulate a CICO situation. To simulate blood flow during puncture, a thin plastic bag filled with simulated blood was placed under the manikin’s artificial skin to enhance the realism for participants during procedures [Appendix 1].

A checklist and questionnaire were formulated to evaluate participants’ psychomotor plus non-technical skills and reactions to the simulation session, respectively.[5,15] The checklist and questionnaire were sent to four experts for validation. The Scale Content Validity Index by Average (S-CVI/Ave) and by Universal Agreement (S-CVI/UA) for the checklist were 0.9 and 0.81, respectively. A pilot run with a different group of participants was conducted to evaluate inter-rater reliability and consistency in assessment [Appendix 2].

For simulation training, participants were invited via a WhatsApp group with details about the date, time, and objectives. Each team was composed of four learners and one embedded participant. On the scheduled day, after initial pre-briefing, an immersive simulation followed by a structured learner-centered debrief using advocacy-inquiry,[16] focusing on learning objectives was conducted. The immersive simulation (S0) was conducted concurrently by both facilitators using the same scripted scenario, and each team participated once in the simulation.

Next day, a 4-hour interactive session covering DAS guidelines and variations in local equipment, patient positioning, and laryngeal handshake was conducted. On day three, participants practiced cricothyroidotomy on a task trainer using rapid-cycle deliberate practice (RCDP).[17] Follow-up simulations took place two weeks and six months post-intervention. The same scenario was run each time with some variations in case descriptions, followed by learner-centered debriefing using advocacy-inquiry.

The impact of this educational intervention was assessed using the Kirkpatrick evaluation model.[18] A pre-study needs assessment was performed to determine training needs and acceptance. Faculty members and senior nurses were asked to rate their dissatisfaction with the current mode of teaching, the need for simulation-based team training for a protocolized approach to airway management, and the potential barriers to implementing this curriculum.

Psychomotor and non-technical skills of teams were assessed using a checklist during all simulation sessions. Each checklist item was scored as follows: 2 for complete and timely, 1 for incomplete or untimely, and 0 for needed but not done, with a maximum score of 100. S1 scores were compared with S0 and S2 to evaluate skill acquisition and retention. Quantitative items such as time to call for help, duration of desaturation, deliberation time, and cricothyroidotomy time were also compared. The incidence of successful cricothyroidotomy, more than three laryngoscopy attempts, and skipping the attempt at supraglottic airway (SAD) insertion were noted. Deliberation time was defined as the time from declaring a CICO situation to starting SCT and cricothyroidotomy time as the time from initiation to the appearance of the capnograph on the monitor. At the six-month follow-up simulation (S2), participants’ reactions were evaluated on a 5-point Likert scale.[19] The perceived change in participants’ behavior was evaluated using a retrospective pre–post-questionnaire, observed changes by faculty and senior nurses during real patient care, and feedback from participants.

Statistical analysis

The sample size was determined using convenience sampling. Data were recorded on Microsoft Excel spreadsheet and analyzed were performed using MedCalc for Windows, version 19.3. Statistical analyses are using descriptive and inferential statistics. Continuous variables were expressed as means [standard deviation (SD)], and paired t-tests were used to compare S0 and S1 scores, S1 and S2 scores, and the retrospective pre–post-questionnaire. Ordinal variables were evaluated using Chi-square tests, with a P value of < 0.05 considered statistically significant.

Results

A total of 24 participants were recruited, including 18 anesthesia trainees and six staff nurses. None had previously undergone simulation-based airway management training. Five participants had prior experience with an unanticipated difficult airway, and one had encountered a CICO (cannot intubate, cannot oxygenate) situation [Figure 1]. The needs assessment revealed a high level of dissatisfaction with the current teaching curriculum for airway management among both faculty and senior nurses [mean (SD) of 4.12 (0.59) and 4.37 (0.63), respectively]. They also agreed on the necessity of simulation-based training for managing airway crises and teaching a protocolized approach (mean scores >4.0) [Figure 2].

Figure 1.

Baseline data of participants; CICO, Cannot intubate, cannot ventilate

Figure 2.

Pre-study needs assessment; Likert scale, 1 – Strongly disagree, 5 – Strongly agree; Data are expressed as mean (SD)

Participants’ reactions to the training curriculum, environment, and facilitators ranged from satisfactory to very satisfactory [Table 1]. Notable improvements in participant and team performance were observed during S1 compared to S0, as demonstrated by a significant increase in technical and non-technical skill scores [mean (SD): 26.7 (6.3) at S0 to 67.8 (7.3) at S1; P < 0.001]. The average time to call for help and the duration of desaturation during the scenario significantly improved from S0 to S1. The mean deliberation time decreased from 100.2 (13.2) seconds at S0 to 38.5 (7.8) seconds at S1 (P < 0.001). Only one team performed successful SCT at S0, whereas all teams completed SCT within 120 seconds at S1. The number of teams making more than three laryngoscopy attempts and skipping SAD insertion also decreased. Skill retention was evident at the six-month simulation session, as overall scores at S2 were not notably different from S1 [mean (SD) at S2: 66.8 (4.1); P = 0.7]. The average time to call for help and the duration of desaturation during the scenario increased at S2 compared to S1. The mean deliberation time at S2 was 43.7 (9.2) seconds, indicating skill retention (P = 0.7) [Table 2].

Table 1.

Reaction of participants to educational intervention on 5-point Likert Scale (1=Strongly disagree, 2=Disagree, 3=Neutral, 4=Agree, 5=Strongly agree)

Reaction question	Median (range)	Likert score (mean±SD)
The scientific material aligns with recent guidelines	4 (3, 5)	4.15±0.58
The learning objectives of the curriculum are appropriate for the learner group	5 (4, 5)	4.3±0.41
The simulation session closely mimics real-world scenarios.	5 (4, 5)	4.45±0.42
The course enhanced my skills in situational awareness, decision-making, and communication.	4 (3, 5)	4.05±0.46
The course improved my psychomotor skills in performing surgical cricothyroidotomy.	4 (4, 5)	4.15±0.38
The facilitators created a supportive environment and provided constructive feedback.	4 (3, 5)	4.25±0.44
The debriefing session by facilitators helped me think of possible solutions.	4 (3, 5)	4.1±0.68
I would recommend to my colleagues to participate in this curriculum.	5 (4, 5)	4.4±0.42

Data are expressed as median (range) (mean±SD); SD, Standard deviation

Table 2.

Comparison of psychomotor and non-technical skills of teams at baseline, post-skill training and at 6-month follow-up simulation

Parameters	Baseline (S0) (n=6)	Post-skill training (S1) (n=6)	At 6 months (S2) (n=6)	P
Time to call for help (sec; mean±SD)	112.8±6.4	69.7±10.2	77.3±8.3	P1<0.001 P2=0.02
Duration of desaturation (sec; mean±SD)	114.2±9.4	86.8±10.5	92.3±7	P1<0.001 P2=0.03
Deliberation time (sec; mean±SD)	100.2±13.2	38.5±7.8	43.7±9.2	P1<0.001 P2=0.7
Cricothyroidotomy time (sec; mean±SD)		107.7±8.7	112.7±7.2	P2=0.4
Successful cricothyroidotomy incidence; n (%)	1 (16.7)	6 (100)	5 (83.3)
More than three times at laryngoscopy; n (%)	4 (66.7)	1 (16.7)	0 (0)
Skipping the attempt at SAD insertion; n (%)	2 (33.3)	0 (0)	1 (16.7)
Composite checklist score (mean±SD)	26.7 (6.3)	67.8 (7.3)	66.8 (4.1)	P1<0.001 P2=0.7

Data presented in mean (SD), number (%); SD=Standard deviation, SAD=Supraglottic airway device; P1, P value for paired t-test between baseline and post-skill training simulation session and P2: P value for paired t-test between post-skill training and at 6 months simulation session

After implementing the curriculum, participants reported significantly higher confidence in managing unanticipated difficult airway situations [mean (SD) score 2.50 (0.58) pre-intervention to 4.25 (0.52) post-intervention; P < 0.001, mean difference = 1.75, 95% confidence interval (CI): 1.43, 2.07]. Systematic approach scores also improved from 2.0 (0.5) to 4.5 (0.5) (P < 0.001, mean difference = 2.5, 95% CI: 2.21, 2.79). Additionally, decision-making during airway crises, communication skills, and situational awareness showed meaningful improvements [Figure 3]. Observations from faculty members and senior nurses in the workplace revealed a noticeable change in participants’ behavior in managing crisis situations and a more protocolized approach to airway management [Figure 4]. Participant feedbacks revealed that simulation-based training had improved their confidence during airway management and their situational awareness during crises [Table 3].

Figure 3.

Retrospective pre–post-comparison of participants; SAD: Supraglottic airway device; Likert scale, 1 – Strongly disagree, 5 – Strongly agree; Data are expressed as mean (SD)

Figure 4.

Observed behavior change in participants during real patient care

Table 3.

Behavior changes among participants after training

	Major themes	Interviews
1	Decision-making and crisis management	“Shortly after completing the curriculum, I encountered a case where a patient’s airway unexpectedly became compromised during induction. The training emphasized the importance of prioritizing interventions based on the patient’s condition and available resources. I was able to apply these principles, assess the situation rapidly, and make decisions that ultimately stabilized the patient’s airway.”
2	Preparedness and confidence	“I used to feel reasonably prepared and confident, but there was always an underlying uncertainty when it came to crisis situations. This curriculum has significantly boosted my confidence and now I feel more prepared to handle any crisis situation.”
3	Skills (technical and non-technical)	“I can handle airway management with much greater confidence and precision. I have also improved my communication and leadership skills and feel more confident working as part of a team.”
4	Resource utilization and protocol adherence	“The curriculum helped design an equipment list based on available resources, which had a significant impact on my ability to utilize resources effectively. The training on various tools and equipment for airway management taught me how to select the appropriate resources for specific situations. This training has made me more adept at quickly identifying and utilizing the best tools for the job.”

Discussion

To the best of our knowledge, this is the first study to evaluate simulation-based assessment of real teams for difficult airway management using validated tools in India. The primary findings indicate that simulation-based training significantly enhanced both technical and non-technical skills in managing CICO situations. This was evidenced by the marked improvement in technical and non-technical skills from baseline to post-training sessions. Notable improvements included the time taken to call for help, initiation and duration of SCT, limited laryngoscopy attempts, and the use of SAD. Observed and perceived improvements in confidence, decision-making during airway crises, protocolized approaches, and teamwork were noted after training.

The previous research has emphasized the effectiveness of simulation training in improving technical and non-technical skills for managing difficult airways, reducing critical missed steps, and fostering a protocolized approach during airway management.[20,21,22,23] However, prior research primarily focused on individual training and assessment.[14,24] In our study, we evaluated the technical and non-technical skills of teams working in real clinical settings during immersive simulation sessions.

It has been suggested that factors beyond airway algorithms, such as personal clinical experience and familiarity with various airway devices, influence emergency airway decision-making. In our study, we adapted the DAS algorithm based on local equipment availability to minimize confusion. Additionally, the proficiency gained during skill training, which included didactics, cognitive aids, video sessions, and hands-on practice, helped the team adhere to a protocolized approach to airway management.

Early airway establishment through surgical cricothyrotomy is recommended in CICO situations to prevent hypoxic brain injury.[5] However, managing CICO situations is challenging due to limited experience, difficulty following protocols, failure to recognize the need for SCT in a timely manner, and reluctance or fixation on one step of the algorithm.[25] Simulation-based training helps address these issues by reducing fixation errors and increasing willingness to perform life-saving procedures. In our study, deliberation time and major protocol deviations significantly decreased during post-training immersive simulation sessions. Simulation-based multi-professional training with actual teams facilitated the effective translation of learning into real clinical practice, as depicted by participant feedbacks and observed behavioral changes.

Skills learned during training for rare events may decay over time due to infrequent use in clinical practice. Simulation training has been shown to be effective in attaining team behavior needed for rare clinical crises, outperforming traditional methods. However, a systematic review and meta-analysis found that while simulation-based training improved performance behavior, it did not consistently translate into improved time-skill or skill retention compared to non-simulation training.[26] In our study, most skills were retained for up to six months, but long-term retention may require ongoing training.

Assessing performance in medical education is challenging due to the need for uniformity during simulation sessions. Assessments should be standardized, validated, and objective to minimize inter-rater variability and ensure accurate evaluations.[27] In our study, we used a validated checklist to objectify the assessment process. Simulations were conducted by instructors with extensive backgrounds in anaesthesiology and simulation teaching.

Key strengths of our study include the use of real teams, validated assessment tools, minimal inter-rater variability, a protocolized approach, and experienced instructors, all of which enhance the effectiveness of training and its clinical applicability. Limitations include being a single-center study; however, the objective assessment and team training incorporated in our study provide a basis for future research. The extent to which simulation-based improvements translate into clinical practice depends on the realism of the simulation. Although simulation cannot fully replace real-life scenarios, our immersive simulation scenarios conducted with real teams facilitated the learners’ experience and the translation of learning to the real patient care area. Through objective assessment using validated checklists, we eliminated subjectivity in evaluating psychomotor and non-technical skills. The study assessed skill retention up to six months post-training and evaluated behavior changes at the bedside. Follow-up studies to determine the long-term impact of the training on patient outcomes are needed.

Conclusions

This study demonstrates that simulation-based multi-professional training significantly enhances both technical and non-technical skills for managing difficult airway situations. The improvement and retention of skills, coupled with behavioral changes in real-world settings, highlight the effectiveness of immersive simulation in preparing teams for critical scenarios like CICO. Ongoing training and future research are needed to assess the long-term impact and translation of training into improved patient outcomes.

Conflicts of interest

There are no conflicts of interest.

Appendix 1.

Scenario script

Category	Description
Complete diagnosis	Can’t intubate can’t oxygenate (CICO) scenario in unanticipated difficult airway in a patient undergoing lumber laminectomy for imminent cord compression
Learners How many, Describe roles	Four: Three resident Doctors and one staff nurse Faculty, junior resident (JR) and senior resident (SR) One staff nurse (SN) SR, JR and SN starts the scene faculty joins later
Embedded participant details	Anaesthesia technician as embedded actor will prompt for gross deviations and steer the scenario
Manikin name, moulage if any	ARES, Mastero Software Right arm IV assess with a drainage bag connected (for collection of fluid/drugs administered), Foleys catheter with urobag, During intubation, pharyngeal obstruction manually for can’t intubate situation and lung stiffness for difficult ventilation by software, to create “Cannot Intubate, Cannot Oxygenate” (CICO) situation with, successive intubation attempt, For possible creation of front of neck access, simulated skin was used to cover the trachea of manikin and possible puncture., a clean, thin sheet filled with simulated blood was placed under the artificial skin of manikin
Learning objectives (SMART)	Systematic approach to the failed intubation in case of unanticipated difficult airway – Plan A to Plan D Recognise problem early, call for help and demonstration of team work
Setting	Skill Lab set as Operating Room
Equipment needed	Airway and breathing: O2 mask with tubing, Bain circuit, Guedel airway, Ambu bag with reservoir and mask, suction catheter size 14,16, ET tubes size 7,7.5 and 8, laryngoscope with all blades, Videolaryngoscope, laryngeal mask airway (LMA), Bougie, Stylet, Plan D equipments: Scalpel with blade, 6mm ID ETT and 16 G needle and jet ventilator), forceps, anaesthesia machine. Nasal cannula Circulation: ECG leads, Stethoscope, BP cuff, IV fluids NS, IV stand, drainage bag. Syringes 2, 5, 10, 20 50ml, Cannula, 3-way stopcock, Tapes to fix. Drugs: Propofol, fentanyl, midazolam, sux, xylocard, Adrenaline, dopamine, bicarbonate, ketamine, fentanyl, midazolam, non depolarising neuromuscular blocking agent (vecuronium or rocuronium).empty vials to be labelled as for SIMULATION PURPOSE ONLY and syringes to be prepared with PROPER LABELS Others: Clothes for manikin, crash cart or table, software, nursing record sheet, ventilator chart, hand sanitizer, gloves
Pre-brief (Describe)- 3 minutes	Welcome, Ice breaking, Environment description about mannequin, difficult intubation cart, monitor, anaesthesia machine, drugs. Skill lab to be converted to OR for realism. Ensure psychological safety of learners at every step of scenario
Case information to be provided to the team by the facilitator	Name: Rahul Age: 45 years Weight: 70 kg Brief history and background: You are anaesthetising a 45 year male, average weight, with no factors suggestive of difficult airway on preoperative assessment that is planned to undergo lumber laminectomy for incipient cord compression. He will be ventilated prone with a cuffed endotracheal tube. Anaesthesia is induced with fentanyl, propofol and atracurium. Proceed as you would normally go.
Additional information to Faculty/actor	Facemask ventilation is adequate initially, difficulty arise after attempts of intubation Keep faculty out of the scenario, join only when someone is calling for help Check SBAR (Situation, Background, Assessment and Recommendation) format of handover to faculty
Scenario stage	Patient condition (ABCDE)	Sim parameter	Expected intervention	Additional info for embedded participant/tech to steer the case
Stage 1: Facemask ventilation (2-3 minutes)	A: Clear B: Assisted C: Normal D: anaesthetised eyes closed	RR- Depends on candidate Minimum chest rise with mask ventilation SpO2:98% HR- 90/min BP: 130/80	Attempts to ventilate with bag and mask--Optimise head and neck position Use of airway adjuncts (Guedel’s airway) Alternative means of oxygenation	Make ventilation difficult if not asked for Guedel’s airway Make ventilation possible with these interventions Ask for which size of airway when asked for it
Stage 2: Can’t intubate) (2-3 minutes)	A: Clear B: Absent C: Normal D: unconscious Eyes closed	HR- 100/min BP- 120/70 SpO2 drop from 98% to 94%	Can’t intubate with normal cuffed endotracheal tube Call for help for faculty Call for difficult intubation cart Second attempt by video laryngoscope and/or bougie	Make deterioration in saturation with subsequent attempts Prompt for call for help
Stage 3: Can’t intubate, can’t oxygenate) (4-5 minutes)	A: Clear B: resistance on ventilate C: feeble D: unconscious Eyes closed	RR- 0 HR- 120 BP- 150/110 SpO2-90% and rapidly falling	faculty join- SBAR brief Insert LMA and ventilate Diagnose CICO situation Activate plan for cricothyroidotomy Optimise position Identify cricothyroid membrane Perform surgical cricothyroidotomy and confirm ventilation Explain to attendants regarding the event	No chest rise on ventilation with LMA If cricothyroidotomy performed and ventilation confirmed then improvement in condition If not then facilitator will pause the scenario
Debrief plan/focus	Acknowledge that it is a simulator. Use GAP analysis AI (Greetings with reactions and summary, Analyze with reflection and advocacy inquiry, Personalize with take home message) Discuss difficult airway protocol for airway management (Plan A to Plan D), CICO situation and management Pick one or two human factors such as Situation awareness, call for help, leadership, and communication
Script/Notes for Actor/SP	Remember you (anaesthesia technician) are there to give information when asked by participants or directed by faculty and act in manner consistent with typical hospital practices. You support the progression of scenario without leading such as When faculty and JR struggle for intubation, facilitate by asking should I ask someone to help us in intubation. Or Should I get a different size endotracheal tube or other intubation aids when attempt at intubation fails? Should we optimise the position? If asked for LMA, ask for which LMA and what size of LMA? Once you have done, close the loop by saying it loudly. Also when everyone is managing the airway, may prompt for fall in saturation if not looked for by asking Should we check for the patient’s oxygen saturation? If condition is not explained to relatives, ask- since the patient is proceeding for surgery or might be shifted to the ICU, should we inform the attendees about the current condition and events? Act as you typically in the hospital

Appendix 2.

Checklist

S no.	Plan	Components	2	1	0
	Technical skill as per DAS guidelines
	Plan A
1.		Head-up positioning and ramping	2	1	0
2.		Preoxygenation	2	1	0
3.		Apnoeic/Paraoxygenation	2	1	0
4.		No of attempts at laryngoscopy (<3 attempts=2, 3-5 attempts=1, >5 attempts=0)	2	1	0
5.		Mask ventilation in between laryngoscopic attempts	2	1	0
6.		External laryngeal manipulation	2	1	0
7.		Use of a bougie or stylet	2	1	0
8.		Use of alternative laryngoscope	2	1	0
9.		Change of operator after first/Second attempt	2	1	0
	Plan B
10.		Failed intubation declared	2	1	0
11.		Second-generation SADs	2	1	0
12.		No. Of attempts at SAD insertion (2 attempts=2, 1 attempts=1, no attempts=0)	2	1	0
	Plan C
13.		Failed SAD ventilation declared	2	1	0
14.		Attempt to oxygenate by face mask with complete muscle paralysis	2	1	0
15.		Declare CICO and start plan D	2	1	0
16.		Continue attempts to oxygenate by face mask, SAD, and nasal cannulae	2	1	0
	Plan D
17.		CICO and progression to front-of-neck access should be declared	2	1	0
18.		Laryngeal handshake	2	0
19.		Patient positioning	2	1	0
20.		Midline longitudinal incision over skin of mannequin	2	1	0
21.		Identification of cricothyroid membrane	2	1	0
22.		Rotating the scalpel for transverse incision	2	1	0
23.		Keep the scalpel in situ till insertion of bougie loaded with 6.0 no ETT	2	1	0
24.		Endotracheal tube railroading over bougie	2	1	0
25.		Confirmation with bilateral air entry and appearance of capnography waveform.	2	1	0
26.		Deliberation time (seconds) (<120 sec=2,120-150=1, 150-180=0)	2	1	0
Team performance
27.		All team members exhibit professional attitude and interactions	2	1	0
28.	Leadership (team members)	There is a clearly identified team leader	2	1	0
29.		Assigns roles to team members	2	1	0
30.		Maximizes skill sets of personnel in assigned roles	2	1	0
31.		Directs/redirects team members effectively	2	1	0
32.		Monitors actions of team members	2	1	0
33.		Addresses specific persons when requesting info/assigning tasks	2	1	0
34.		Uses closed loop communication (orders directed & confirmed)	2	1	0
35.	Team work	Resolves conflicts	2	1	0
36.		Engages team members in decision making	2	1	0
37.		Recruits additional personnel when appropriate	2	1	0
38.		Maintains global view (does not get sidetracked by procedures, details)	2	1	0
39.		Performs tasks in appropriate sequence/prioritizes well	2	1	0
40.		Reprioritizes for urgent/emergent events	2	1	0
41.		Avoids fixation errors (considers full differential for problems encountered)	2	1	0
42.		Summarizes case for transfer of care	2	1	0
43.	Team members	Carry out tasks in appropriate sequence	2	1	0
44.		Stay in roles, appropriately	2	1	0
45.		Adjust roles to address urgent events, appropriately	2	1	0
46.		Verbalize questions/info to team leader	2	1	0
47.		Use close loop communication (confirm orders, task completion)	2	1	0
48.		Ask for assistance if unable to complete task/balance workload	2	1	0
49.		Engage in decision making	2	1	0
50.		Suggest additional resources (personnel, etc) appropriately	2	1	0

Funding Statement

Nil.