Abstract
Background
Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID‐19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees.
Methods
This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre‐pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first‐attempt success and adverse airway outcomes between the two periods.
Results
There were 1129 intubations performed pre‐pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID‐19 airway protocol—8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre‐pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre‐pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first‐attempt success nor adverse airway outcomes differed between pre‐pandemic and pandemic periods.
Conclusions
The COVID‐19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.
INTRODUCTION
Tracheal intubation of pediatric patients in the emergency department (ED) poses an educational challenge due to its relative infrequency yet critical importance. Research has shown that while greater experience correlates with procedural success, achieving and maintaining advanced airway competency can be challenging for emergency physicians who care for children. 1 , 2 , 3 , 4 , 5 , 6 While simulations and use of recordings from videolaryngoscopy are alternative instructional methods, clinical experience remains crucial to endowing physicians and physicians‐in‐training with the requisite procedural skills to successfully intubate children in the ED. 7 , 8 Decisions of the appropriate laryngoscopist to attempt tracheal intubation when dealing with critically ill children require balancing educational benefit with patient safety and likelihood of success.
To reduce the risk of airborne transmission during the COVID‐19 pandemic, institutions developed or modified protocols around airway management to limit staff exposure. 9 , 10 , 11 Additionally, public health measures such as school closures, stay‐at‐home orders, and mandatory social distancing concurrently altered pediatric ED volumes and patient mix. 12 , 13 , 14 All of these factors potentially impacted educational opportunities for tracheal intubation of pediatric patients in the ED for physicians‐in‐training in two major ways: decreasing overall procedural opportunities and shifting the allocation of intubation opportunities. To date, however, no studies to our knowledge have described the impact of the pandemic on pediatric intubation frequency or performance.
In this multicenter, observational study, we sought to determine the impact of COVID‐19 airway protocols on both the educational opportunities of pediatric trainees and intubation outcomes. We hypothesized that physician trainees would have fewer opportunities to perform tracheal intubation due to the impact of COVID‐19 on the total number of intubation opportunities and the decision about who should attempt intubation, providing a natural experiment to explore the benefits and drawbacks of shifting laryngoscopy responsibilities away from trainees.
METHODS
Design and setting
This study used prospectively collected quality improvement and educational datasets from of North American pediatric EDs. Participating centers were either members of the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. One site was a member of both NEAR4KIDS and the airway education collaborative. The NEAR4KIDS site leaders or their designee follow an approved compliance plan in entering data on a standard collection form for each intubation in near real‐time. 15 For non‐NEAR4KIDS centers, each site recorded patient and procedural data and intubation outcomes into a secured educational database hosted by Boston Children's Hospital using the NEAR4KIDS operational definitions. Site principal investigators performed quality assurance and completed additional data extraction when required.
Approvals by site‐specific Institutional Review Boards and data use agreements exist between all NEAR4KIDS sites, and this study was approved by the NEAR4KIDS Manuscript Oversight Committee. For the sites in the education collaborative that were not part of NEAR4KIDS, the study was deemed exempt by Institutional Review Boards at all participating sites: Boston Children's Hospital, Cincinnati Children's Hospital, and the Children's Hospital Colorado. Data use agreements were established among these three institutions.
Data collection
Data collection began with collecting site‐specific intubation‐related protocols created or modified in response to the COVID‐19 pandemic. The data included patient, proceduralists, and practice characteristics. The proceduralist characteristics included the specialty and training level of the primary laryngoscopist who performed tracheal intubation. Data from encounters from the site participating in both consortiums were included only once.
Pre‐pandemic was defined as the 3 years leading up to the declaration of the COVID‐19 pandemic by the World Health Organization (January 1, 2017–March 10, 2020). The pandemic period was defined as the subsequent 12 months (March 11, 2020–March 10, 2021). De‐identified study data were reported through the electronic data capture tools of the secure web‐based software REDCap hosted by Boston Children's Hospital (Version 11.1.17, Vanderbilt University). 16
Outcomes
Clinical outcome data included number and outcome of attempts and adverse airway outcomes 15 : cardiac arrest, dysrhythmia, emesis with and without aspiration, hypotension, laryngospasm, lip or dental injury, mainstem intubation, mucosal injury, pneumothorax or pneumomediastinum, and unrecognized esophageal intubation. Occurrence of hypoxia during the intubation attempt also was considered an adverse airway outcome. Hypoxemia during intubation was measured dichotomously (yes or no). When the lowest oxygen saturation was also available, it was used to classify hypoxia as moderate (80–89%) or severe (<80%). Aspiration, cardiac arrest, hypotension, severe hypoxia, and unrecognized esophageal intubations were considered severe adverse airway outcomes.
Analysis
Protocols were analyzed based on predefined categories including changes to personnel performing the procedure, approach to oxygenation, equipment selection, and additional measures for staff protection.
The study compared patient, proceduralist, and practice characteristics and clinical outcomes between the pre‐pandemic and pandemic time periods with Chi square or Fisher's exact tests for categorical variables and Wilcoxon‐rank sum tests for non‐normally distributed continuous variables. Both the proportional and absolute frequency of intubation opportunities were compared by laryngoscopist level of training and specialty for the pre‐ and pandemic periods. Proportional frequency was defined as the percentage of all intubation opportunities attempted by a given training level and medical specialty during the study period. The absolute frequency was the total number of monthly intubation attempts across all sites attempted by a given training level and specialty. The monthly pandemic incidence of intubation attempts for patients less than 12 months old and for older patients was compared to the pre‐pandemic incidences using incidence rate ratios. The 12‐month cut point was chosen because infants less than 1 year old have a lower rate of first‐attempt success, reflected in prior use of this categorization in studies of pediatric airway management. 17 , 18
Multivariable regression models were used to estimate the adjusted odds ratio of first‐attempt success and presence of adverse airway outcomes by laryngoscopist level of training, controlling for factors with known associations with attempt success, including patient age, presence of difficult airway risk factors, primary respiratory indication for intubation, and the use of neuromuscular blocking agents. For the multivariable logistic regression model, we transformed age into a categorical variable to compare infants (age less than 1 year) with all others. 17 Intubations with missing data were included in univariate analyses if required data were available but were excluded from the multivariable analysis if they were missing any relevant data. The adjusted incident rate ratio was reported with a point estimate and 95 percent confidence intervals (CI). Statistical analyses were performed using Stata 17 from StataCorp LLC (College Station, Texas).
RESULTS
Pandemic airway protocols
Descriptive analyses of the 10 sites that provided protocols are detailed in Table S1. Protocols were consistently centered on reducing intubation attempts to limit personnel exposure to Sars‐CoV‐2. The most common protocol changes included limiting the number of in‐room personnel, ensuring intubations were performed by experienced laryngoscopists, and universally advocating for videolaryngoscopy. Eight sites delineated who could perform laryngoscopy, with four of those sites reserving tracheal intubation attempts for more experienced laryngoscopists. The definition of “experienced” differed across sites, with protocols including emergency medicine residents, pediatric emergency medicine fellows, pediatric emergency medicine attendings, and/or pediatric anesthesiologists. Two sites reported lowering the threshold to call for airway back‐up teams during the pandemic. The approach to peri‐procedural oxygenation during the pandemic varied across sites, with some utilizing preoxygenation and apneic oxygenation to mitigate the risk of desaturation, and others advising against active oxygenation strategies to minimize aerosolizing viral particles.
Enrollment
During the four‐year study period, a total of 1412 intubations were reported from 11 EDs: 1129 pre‐pandemic and 283 during the pandemic. Patient and site characteristics are shown in Table 1 and Table S2. Patients intubated during the pandemic were older (median age 52 months [IQR: 13, 146] versus 36 months [IQR: 8, 123] pre‐pandemic, p = 0.01) and less likely intubated for a respiratory indication (44.2% versus 53.9% pre‐pandemic, p < 0.01).
TABLE 1.
Patient and site characteristics
| Comparison between eras | |||
|---|---|---|---|
| Pre‐Pandemic | Pandemic | p value | |
| Patient characteristics (n = 1412) | |||
| Median age in months [IQR] | 36.0 [7.6, 123.0] | 52.0 [13.0, 146] | 0.01 |
| Male sex (n = 1407) | 637 (56.6) | 164 (58.4) | 0.59 |
| Difficulty airway risk factor present (n = 904) | 322 (43.6) | 72 (43.4) | 0.95 |
| Indication | |||
| Cardiac/Arrest | 71 (6.3) | 21 (7.4) | 0.49 |
| Neurologic | 503 (44.6) | 135 (47.7) | 0.34 |
| Respiratory | 608 (53.9) | 125 (44.2) | < 0.01 |
| Shock/Sepsis | 224 (19.8) | 57 (20.1) | 0.91 |
| Trauma | 177 (15.7) | 57 (20.1) | 0.07 |
| Missing | 43 (3.8) | 8 (2.8) | 0.43 |
| Initial SpO2 saturation (n = 1100) | 98.0 [87.0, 100.0] | 97.0 [87.0, 100.0] | 0.75 |
| Site characteristics | |||
| Median patients intubated per month [IQR] | 3.0 [2.0, 5.0] | 2.0 [1.0, 4.0] | |
| Use of video‐assisted laryngoscopy | 725 (75.1) | 221 (80.4) | 0.07 |
Note: Median [IQR] or number (proportion).
Outcomes
Proceduralist characteristics for the first two attempts of these intubations are shown in Tables 2 and 3. Pediatric residents and pediatric emergency medicine fellows performed proportionally fewer first attempts during the pandemic: pediatric residents accounted for 1.1% of all first attempts versus 6.4% pre‐pandemic (p < 0.01), and pediatric emergency medicine fellows accounted for 38.4% of all first attempts versus 47.2% pre‐pandemic (p = 0.01). Pediatric emergency medicine fellows accounted for proportionally fewer second attempts during the pandemic as well. The result was a significant decrease in monthly intubation opportunities for both groups. Although emergency medicine residents experienced a downward trend in first attempt opportunities, this drop was not statistically significant, and this group proportionally accounted for more second attempts during the pandemic. Emergency medicine faculty and anesthesiologists performed proportionately more initial intubation attempts during the pandemic.
TABLE 2.
Proportion of intubation attempts by specialty and training level
| Laryngoscopist | First attempt | Second attempt | ||||
|---|---|---|---|---|---|---|
| Pre‐pandemic n (%) | Pandemic n (%) | p value | Pre‐pandemic n (%) | Pandemic n (%) | p value | |
| Resident | ||||||
| Emergency Medicine | 211 (19.3) | 51 (18.2) | 0.67 | 30 (10.2) | 14 (12.9) | 0.01 |
| Pediatrics | 70 (6.4) | 3 (1.1) | < 0.01 | 15 (5.1) | 0 (0.0) | 0.06 |
| Other | 8 (0.7) | 1 (0.4) | 0.49 | 3 (1.0) | 0 (0.0) | 0.4 |
| Fellow | ||||||
| Pediatric Emergency Medicine | 516 (47.2) | 108 (38.4) | 0.01 | 126 (43.0) | 17 (25.6) | 0.02 |
| Anesthesia/ICU | 31 (2.8) | 13 (4.6) | 0.13 | 19 (6.5) | 3 (4.7) | 0.59 |
| Other | 1 (0.1) | 1 (0.4) | 0.30 | 0 (0.0) | 1 (1.6) | 0.03 |
| Attending | ||||||
| Pediatric Emergency Medicine | 96 (8.8) | 42 (15.0) | < 0.01 | 43 (14.7) | 14 (21.9) | 0.15 |
| Anesthesia/ICU | 34 (3.1) | 10 (3.6) | 0.7 | 21 (7.2) | 7 (10.9) | 0.31 |
| Other | 1 (0.1) | 1 (0.4) | 0.30 | 0 (0.0) | 0 (0.0) | N/A |
| Anesthesia (Level Unspecified) | 33 (3.0) | 17 (6.1) | 0.02 | 15 (5.1) | 5 (7.8) | 0.40 |
| Other Specialty | 94 (8.6) | 34 (12.1) | 0.07 | 21 (7.2) | 3 (4.7) | 0.47 |
TABLE 3.
Incidence of intubation opportunities per month a by specialty and training level
| Laryngoscopist | First attempt | Second attempt | ||||
|---|---|---|---|---|---|---|
| Pre‐pandemic | Pandemic | p value | Pre‐pandemic | Pandemic | p value | |
| Resident | ||||||
| Emergency Medicine | 5.51 | 4.14 | 0.06 | 0.78 | 1.14 | 0.26 |
| Pediatrics | 1.83 | 0.24 | < 0.01 | 0.39 | 0.00 | 0.02 |
| Other | 0.21 | 0.08 | 0.40 | 0.08 | 0.00 | 0.43 |
| Fellow | ||||||
| Pediatric Emergency Medicine | 13.48 | 8.76 | < 0.01 | 3.29 | 1.38 | < 0.01 |
| Anesthesia/ICU | 0.81 | 1.05 | 0.42 | 0.50 | 0.24 | 0.25 |
| Other | 0.03 | 0.08 | 0.49 | 0.0 | 0.08 | 0.24 |
| Attending | ||||||
| Pediatric Emergency Medicine | 2.51 | 3.41 | 0.10 | 1.12 | 1.14 | 0.95 |
| Anesthesia/ICU | 0.89 | 0.81 | 0.82 | 0.55 | 0.57 | 0.91 |
| Other | 0.03 | 0.08 | 0.49 | 0.00 | 0.00 | N/A |
| Anesthesia (Level Unspecified) | 0.86 | 1.38 | 0.13 | 0.39 | 0.41 | 0.92 |
| Other Specialty | 2.46 | 2.76 | 0.56 | 0.55 | 0.24 | 0.18 |
Incidence per month is cumulative across all 11 sites.
The monthly incidence of tracheal intubation opportunities for patients younger than 1 year compared to older children is shown in Figure 1. Pediatric emergency medicine fellows had a lower incidence of intubation opportunities during the pandemic when compared to pre‐pandemic, with the most pronounced decrease in patients less than 1 year of age; incidence rate ratio = 0.35 (95% CI: 0.20, 0.57 for patients <1 year old) and 0.79 (95% CI: 0.62, 0.99 for patients ≥1 year old). Emergency medicine attending physicians had a higher incidence of intubation opportunities in older children during the pandemic, with an incidence rate ratio of 1.60 when compared to pre‐pandemic, although the 95% CI includes 1 (95% CI:1.00, 2.51).
FIGURE 1.
Incidence of Intubation attempts by specialty and training level. Panel A: Patients <1 year of age Incidence Rate Ratio (95% CI) comparing pandemic to pre‐pandemic cumulative monthly incidence across all 11 sites: 0.67 (0.30, 1.36) for EM Residents, 0.35 (0.20, 0.57) for PEM Fellows, and 0.95 (0.44, 1.90) for EM Attendings. EM, Emergency Medicine; PEM, Pediatric Emergency Medicine. Panel B: Patients ≥1 year of age Incidence Rate Ratio (95% CI) comparing pandemic to pre‐pandemic cumulative monthly incidence across all 11 sites: 0.77 (0.53, 1.1) for EM Residents, 0.79 (0.62, 0.99) for PEM Fellows, and 1.60 (1.00, 2.51) for EM Attendings. EM, Emergency Medicine; PEM, Pediatric Emergency Medicine.
The overall rate of first‐attempt success was not significantly different between the two time periods: 69.6% pre‐pandemic versus 71.5% during the pandemic (p = 0.53). First‐attempt success also did not vary by training level of the laryngoscopist, even after adjusting for co‐variates (Table 4). There were no significant differences in the pre‐pandemic and pandemic rates of adverse airway outcomes (30% pre‐pandemic vs. 33% pandemic, p = 0.3) and of severe adverse airway outcomes (17% pre‐pandemic vs. 18% pandemic, p = 0.6). Similarly, there was no significant difference in the overall rate of hypoxia (19% pre‐pandemic vs. 24% pandemic, p = 0.06), nor any change in the rate of severe hypoxia (19% pre‐pandemic vs. 18% pandemic, p = 0.59).
TABLE 4.
First attempt success by laryngoscopist type
| Pre‐pandemic odds ratio (95% CI) | Pandemic odds ratio (95% CI) | |
|---|---|---|
| Age <1 year | 0.39 (0.26, 0.58) | 0.36 (0.16, 0.85) |
| Respiratory indication | 0.55 (0.40, 0.75) | 0.34 (0.18, 0.64) |
| Difficulty airway risk factor | 0.66 (0.57, 0.77) | 1.79 (0.67, 4.76) |
| Use of NMBA | 2.18 (1.52, 3.13) | 0.64 (0.17, 2.39) |
| Use of video‐assisted laryngoscopy | 1.78 (1.12, 2.84) | 2.10 (0.80, 5.48) |
| Laryngoscopist | ||
| Emergency medicine attending | Reference | Reference |
| Pediatric emergency medicine fellow | 0.73 (0.40, 1.36) | 0.88 (0.59, 1.32) |
| Emergency medicine resident | 1.42 (0.83, 2.44) | 0.47 (0.13, 1.68) |
| Other a | 1.42 (0.81, 2.49) | 0.78 (0.38, 1.62) |
a
Other includes pediatric resident, anesthesia resident, otorhinolaryngology resident, anesthesia/critical care fellow, otorhinolaryngology fellow, anesthesia/critical care attending, otorhinolaryngology attending, other specialty, and anesthesia (level unspecified).
Tested for difference in laryngoscopist effect by time period: no significant interaction between pandemic era and laryngoscopist.
DISCUSSION
Changes to institutional policies and patient characteristics resulted in fewer pediatric ED intubation opportunities for pediatric residents and pediatric emergency medicine fellows during the first year of the COVID‐19 pandemic. These changes did not appear to impact clinical outcomes despite involvement of more senior laryngoscopists. Our findings imply a potential deficit of sufficient opportunities to achieve or maintain competency for current physicians and physicians‐in‐training practicing emergency medicine for children. They can also inform future decisions about the necessity of shifting responsibilities for intubation to improve clinical outcomes.
Fewer intubation opportunities have important implications for the clinical competency of physicians providing emergency care for children during the COVID‐19 pandemic and beyond. Previous work has shown rapid improvement in intubation success over a laryngoscopist's first 20 attempts; however, upwards of 25 to 50 opportunities are typically required before an individual achieves a routine success rate of at least 90 percent. 1 , 19 , 20 For both practicing physicians and physicians‐in‐training, achieving such numbers is challenging. Multiple studies have documented failure of pediatric trainees to achieve competency in intubation by the end of their residency training. 5 , 15 , 21 , 22 Opportunities to perform intubation in an ED setting remain rare during fellowship and in practice. 23 Mittiga and colleagues found that pediatric emergency medicine fellows perform a median of 2.5 intubations per year, with one in 10 fellows spanning a full calendar year without an attempt; opportunities for emergency medicine residents to intubate children are even less frequent. 24 While attending physicians may cumulatively achieve a larger number of attempts, infrequent attempts make it difficult to maintain proficiency. 6 A prior study of greater than 50,000 intubations at over 130 facilities found an incidence of 0.1 pediatric intubations per 1000 clinical hours worked by emergency medicine faculty. 25
Compounding the challenge of low baseline procedural experiences, our study found a 25 percent drop in monthly first‐attempt opportunities and 50 percent fall in monthly second‐attempt intubation opportunities among pediatric emergency medicine fellows during the first year of the pandemic. The incidence of intubation opportunities for emergency medicine residents in pediatric EDs remained low throughout the pre‐ and pandemic eras, especially among patients less than 1 year old. Future physicians who completed their training during the COVID‐19 pandemic may be less likely to have achieved competency in pediatric intubation. Given the decrease in intubation opportunities from an already low baseline, alternative training strategies, such as operating room exposure during anesthesia rotations, increased use of simulation and airway trainers and leveraging videolaryngoscopy for real‐time or remote coaching all represent potential tools for helping this cohort achieve clinical competency in pediatric intubation. 7 , 8 The low frequency of intubation opportunities for pediatric emergency medicine fellows, many of who trained in pediatric residencies with limited or no opportunities for intubation, has important implications for pediatric centers that seek to train both pediatric emergency medicine fellows and rotating emergency medicine residents. 21 , 26 If such sites must preserve intubations for pediatric emergency medicine fellows, it may be necessary to create additional opportunities for emergency medicine residents to perform intubations in pediatric clinical settings other than the emergency department.
Furthermore, changes resulting in decreased clinical intubation experience for physicians‐in‐training did not translate into improved patient outcomes. When drafting policy changes in response to the COVID‐19 pandemic, all sites expressed a desire to optimize intubation success and limit exposure of staff to SARS‐CoV‐2. To achieve this, most sites specified that intubations should be performed by more experienced physicians. However, despite an increased proportion of intubations performed by emergency medicine attendings and anesthesiologists, there was no improvement in either first‐attempt success or frequency of adverse airway outcomes. Overall first‐attempt success was only 70 percent, unchanged from pre‐pandemic levels, with almost one‐third of patients experiencing an adverse airway outcome. The lack of improvement is striking given the change in patient mix. The COVID‐19 pandemic impacted the transmission of other pediatric respiratory viruses, resulting in a decrease in children presenting with respiratory illnesses. 27 Our study reflects this changing epidemiology: patients requiring intubation during pandemic were older and less frequently intubated for a primary respiratory indication. First‐attempt success has been traditionally better with older children and intubation for non‐respiratory indications, but this expected increase was not seen during the COVID‐19 pandemic. 2 , 17 , 28
Our findings can help inform future institutional responses that must balance patient and staff safety with educational opportunities. Sites varied widely in how they defined an experienced laryngoscopist, with some including residents and fellows while others limited attempts to attendings and anesthesiologists. This variation suggests that identifying the most experienced laryngoscopist is complicated—experience depends on cumulative procedural opportunities but also recency of intubation attempts, as well as familiarity with the environment. Although some studies show increased first‐attempt success with increasing experience, a recent study by Pallin of 1000 pediatric intubations found lower success for attendings compared to trainees. 15 , 17 The authors hypothesized that this may be related to attendings being assigned more difficult intubations or to skill degradation related to the infrequency with which they intubate. Our data challenge these hypotheses, as our study found that despite more opportunities in traditionally less difficult intubations, attendings were not more successful than trainees. Skill degradation could certainly play a role, making an argument for the need for continued regular simulation and education in airway management for attendings. 23 , 29 , 30 The data on protocols may offer additional insight into why this expected increase in first‐attempt success did not occur. Thirty percent of sites limited oxygenation around intubation attempts during the pandemic with no resulting change in the rate of hypoxia or severe hypoxia. The fact that hypoxia did not occur more commonly despite some sites limiting oxygenation could reflect the increased proportion of patients intubated for non‐respiratory indications and/or a preference for multiple intubation attempts over allowing hypoxia.
In addition, our study as well as those of Pallin and Capone documented increasing use of videolaryngoscopy. 15 , 17 Videolaryngoscopy provides a shared view, allowing attendings to act as coaching laryngoscopists and provide active real‐time feedback during intubations. 7 This can allow for combining the motor experience of trainees who perform intubations more frequently with the cumulative experience of supervising attendings. Videolaryngoscopy has led to increased opportunities for trainees to have additional attempts during a given patient encounter, which is important given the stable low frequency of pediatric patients requiring intubation during their ED visit. 24 , 31 In addition, videolaryngoscopy allows for sharing that enables real‐time exposure and remote coaching for physicians not directly performing laryngoscopy. Ultimately, the natural experiment provided by the COVID‐19 pandemic has highlighted the need to creatively increase opportunities to improve competency in intubation for all levels of physicians and physicians‐in‐training who provide emergency care for children and videolaryngoscopy provides a usual tool to do so. 7
Limitations
This study relies on sites inputting accurate and complete data into the NEAR4KIDS or their respective quality assurance databases. Participating sites in the NEAR4KIDs followed their compliance plan to ensure >95% intubation capture and data verification. 15 However, the data accuracy could not be independently verified because only de‐identified data were submitted and used for the study. All study sites were pediatric EDs, so these results do not capture intubations performed in EDs that care for low pediatric volumes. While we showed decreased intubation opportunities for trainees in pediatric EDs, emergency medicine residents and pediatric emergency medicine fellows can gain relevant experience by performing adult intubations in the ED or other clinical locations such as intensive care units. Finally, the trend toward fewer intubations for respiratory indications among pediatric patients stands in contrast to the increased burden of severe respiratory disease seen among adult ED patients during this period. 32 Our findings that shifting intubation opportunities did not impact outcomes cannot be generalized to this different adult patient population.
CONCLUSIONS
The COVID‐19 pandemic resulted in decreased proportion and incidence of intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without a change in clinical outcomes. We should consider how to increase intubation experience to help current trainees achieve competency, and possibly reconsider the necessity of limiting trainee attempts in the future. Finally, recognizing that relying on clinical experience may not achieve or maintain competency in this infrequent life‐saving procedure, we should continue to look for innovative opportunities to complement clinical experience to improve competency in intubation for all levels of physicians and physicians‐in‐training who provide emergency care for children.
AUTHOR CONTRIBUTIONS
KM and JN conceived and designed the study. KM, AD, AM, PT, BK, TN, MG, MP, RB, JD, AJ, JN, and AN participated in data collection and management. GD and MM provided statistical advice on study design and analyzed the data; AN chaired NEAR4KIDS Manuscript Oversight Committee with assistance from RW and MP; KM drafted the manuscript, and all authors contributed substantially to its revision. KM takes responsibility for the paper as a whole.
FUNDING INFORMATION
No funding to disclose
CONFLICTS OF INTEREST
All authors report no conflicts of interest.
Supporting information
Table S1.
Table S2.
Miller KA, Dechnik A, Miller AF, et al. See one, see one, teach one – Decisions on allocating intubation opportunities in pediatric emergency medicine. AEM Educ Train. 2022;6:e10830. doi: 10.1002/aet2.10830
Meetings: Presented in May 2022 at the Annual Meeting of the Pediatric Academic Societies in Denver, Colorado
Akira Nishisaki and Joshua Nagler are co‐senior authors.
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Supplementary Materials
Table S1.
Table S2.