Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study
Introduction
The ability to successfully perform critical procedural skills is fundamental to the care of seriously ill and injured children. Effective management of the pediatric airway is central to such resuscitative efforts. Pediatric arrest more commonly results from respiratory rather than cardiac etiology, and therefore early and effective airway management can be life-saving [1].
Critical illness and injury occurs less commonly in children than in adults [[2], [3], [4], [5]]. Data suggest that the need for endotracheal intubation in pediatric patients presenting to the emergency department (ED) ranges from 0.6 to 3.3 cases per thousand visits [6,7]. Therefore, clinical opportunities for emergency medicine (EM) physicians to manage pediatric airways may be limited. For EDs seeing small volumes of children, the absolute number of airway procedures performed will therefore be very low. Even for high volume pediatric EDs, including tertiary care children's hospitals, clinical opportunities are often directed first toward those in training, or divided amongst a large number of practicing EM physicians or other airway specialists [8]. The result is a relative paucity of clinical opportunities to manage pediatric airways, with the potential for long intervals during which such airway management skills are not utilized [8,9].
Prior investigations have aimed to determine how frequently EM physicians perform airway management skills in children. Available data comes largely from investigations that provide single center estimates or focus on institutional rather than physician level experience [[7], [8], [9], [10], [11], [12], [13], [14]]. One study surveyed EM physicians throughout the United States, but had a relatively low survey response rate and did not include physicians in other parts of the world [15]. In addition, prior queries have not captured experience across the entire spectrum of airway management procedures.
The relative infrequency of clinical experiences including pediatric airway procedures may also negatively impact the confidence of EM physicians. Surveys of clinicians who care for children in the emergency setting suggest that maintenance of airways skills is perceived to be important, however inadequate clinical opportunities result in a lack of comfort with pediatric airway management [7,15,16]. The relationship between clinical experience and procedural confidence with regard to pediatric airway procedures has not been well defined.
Section snippets
Objectives
Our primary objective was to assess the clinical experience of practicing EM physicians with pediatric airway procedures, including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways. Our secondary objective was to investigate EM physicians' confidence in their ability to perform these procedures, and to determine predictors of such confidence.
Study design
This was an international, multicenter, cross-sectional survey study of senior practicing EM physicians working in EDs affiliated with Pediatric Emergency Research Networks (PERN) [17].
Setting
Participating hospitals were affiliated with one of the following research networks: Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC, USA), Pediatric Emergency Care Applied Research Network (PECARN, USA), Pediatric Emergency Research Canada (PERC, Canada), Pediatric Emergency Research in
Results
The survey was distributed to 2446 eligible physicians in EDs across the six PEM research networks within PERN, with 1602 (65.4%) respondents providing data on performance and confidence for any of the airway procedures. Table 1 provides an overview of the clinical settings and demographic data. Overall, 96 hospitals across fifteen countries were represented. Approximately half of the respondents practiced in North America. Of the 1602 respondents 1268 (79.2%) had completed post-graduate
Discussion
Emergency medicine physicians must be prepared to resuscitate ill and injured children, including timely performance of critical procedures when necessary. Perhaps the most important of these life-saving skills is the ability to manage the airway [21,22]. However, critical illness is relatively infrequent in children, limiting the exposure to such procedures for PEM physicians. Our study provides a broad evaluation of physician experience for several key emergency airway procedures at nearly
Conclusion
We report on airway procedural exposures for a wide sampling of senior EM physicians across the world. Apart from BMV, exposure to other emergency airway procedures in children was low. Notably, one quarter of senior EM physicians had not performed or supervised endotracheal intubation in the last year. Hands-on practice, performance or supervision of airway procedures were associated with increased procedural confidence; the strength of this association varied by procedure.
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Author's contributions
Dr. Nagler: Conceptualization, Data curation, Writing - original draft; Writing - reivew and editing.
Dr. Simon: Conceptualization, Data curation, Writing - reivew and editing.
Dr. Monuteaux: Formal analysis; Writing - review and editing.
All other authors: Conceptualization, Data curation, Writing - review and editing.
Funding source
Stuart Dalziel's time was part funded by the Health Research Council of New Zealand (HRC13/556). Franz Babl and Ed Oakley are funded by the National Health and Medical Research Council, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560), Canberra, Australia; and supported by the Victorian Government's Infrastructure Support Program, Melbourne, Australia. Franz Babl's time was part funded by a grant from the Royal Children's Hospital Foundation, Melbourne, Australia, and
Declaration of Competing Interest
The authors have no conflicts of interest relevant to this article to disclose.
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Participating networks include: the Pediatric Emergency Care Applied Research Network (PECARN), the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM-CRC), Pediatric Emergency Research Canada (PERC), Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI), Pediatric Research in Emergency Departments International Collaborative (PREDICT), Research in European Pediatric Emergency Medicine (REPEM), and Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoaméricana (RIDEPLA).