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Identifying Objective Performance Errors During Intubation

October 4, 2023

Written by Aaron Lacy

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Using intubation videos, this group identified 13 key performance errors that occur during laryngoscopy. Read more to see what the proceduralists did wrong.

Take your airway QI to the next level
A feature of videolaryngoscopes is the ability to record and review footage of the laryngoscopy, but this can be a subjective and qualitative process. This author group sought to create a taxonomy of errors that occurred during suboptimal emergency intubation procedures.

Videos flagged as suboptimal laryngoscopy attempts (n=100) were reviewed by three emergency physician airway experts and coded for 13 predetermined performance errors, with a primary outcome of incidence of each error during emergency intubation. These errors are categorized below:

Errors of structure recognition during laryngoscope insertion

  1. Insertion off midline leading to esophageal visualization (n=35)
  2. Overly deep insertion leading to esophageal visualization (n=30)
  3. Missed anatomic structure recognition (n=25)
  4. Inadequate suction (n=17)

    Errors of vallecula manipulation
  5. Inadequate lifting force (n=45)
  6. Failure to engage midline of vallecula (n=40)
  7. Lost seating in vallecula (n=31)
  8. Not fully seated in vallecula (n=26)
  9. Too much force in vallecula (n=11)

    Errors of device delivery
  10. Bougie delivery issue (n=39)
  11. Over-rotated insertion Kovacs Sign (n=25)
  12. Tube delivery issues (n=24)
  13. Premature withdrawal of camera (n=9)

*Cohen’s kappa ranged from 0.81-1.00 (strong to almost perfect agreement) for all coded errors. Pooled kappa was 0.901 (95% CI 0.882-0.931).

A few thoughts:
Overriding the epiglottis (Mac as Miller), occurred in 40% of airways and was not coded as a performance error, as part of the airway teaching at this hospital is the option to use this technique deliberately. This technique can lead to a view that is too proximal to the vocal cords leading to difficulty with ETT passage. I doubt all 40 instances of this were intentional, but it would be difficult during video review alone to determine intent. This institution used a bougie first approach to intubation. It’s also not possible to know if proceduralists were using direct or indirect (on-screen) visualization when coding for errors. These factors, which are all acknowledge by the authors, limit the generalizability of the study. Despite these limitations, this taxonomy is an important effort in crafting a universal language in emergency intubation research and QI.

How will this change my practice?
I regularly record trainee intubations and review them with the proceduralist, which is somewhat of a qualitative process. I will be referencing this taxonomy when I review film to better articulate and identify what can be done to improve future intubations.

Editors Note: Due to de-identification of the data, user experience was not included in the analysis. ~ Nick Zelt

A taxonomy of key performance errors for emergency intubation. AJEM. 2023. Nov;73:137-144. Doi: 10.1016/j.ajem.2023.08.035.

One thought on “Identifying Objective Performance Errors During Intubation

  • Over-Rotation/Too Close was one of the performance errors and therefore would have included any issues with Mac-as-Miller–this is not generally an issue with standard geometry blades, though it can be seen with previous generation Storz disposable Mac blades.

What are your thoughts?