Guidance for Novice Airway Training

Background

Every year more than 1000 trainees undertake training in anaesthesia and are required to complete the Initial Assessment of Competence (IAC).  Of these, around 600 come via Core Anaesthetic Training (CAT) or Acute Care Common Stem (ACCS) anaesthetic exit.  The remainder are ACCS trainees exiting to Emergency Medicine or Acute Medicine or ICM trainees.

The skills required to complete the IAC are outlined in the 2010 Anaesthetic Curriculum annex B.  This requires the acquisition of a number of skills in airway management, including the following: 

• maintains the airway with oral/nasopharyngeal airways 
• ventilates the lungs with a bag and mask 
• inserts and confirms placement of a Laryngeal Mask Airway 
• successfully places nasal/oral tracheal tubes using direct laryngoscopy
• correctly conducts RSI.

These skills must be assessed as competent as part of the IAC before work is undertaken without direct supervision.  All training required to complete the IAC is undertaken in a supernumerary capacity which places considerable demands on anaesthetic departments.  

Current situation

The COVID pandemic has led to several important changes that will have a detrimental impact on departments’ ability to undertake novice training.  Firstly, advice on airway management that was produced by the joint COVID expert group (representing the RCoA, Association of Anaesthetists, FICM and ICS) in partnership with the Difficult Airway Society (DAS).  This included the use endotracheal intubation using video laryngoscopy (VL) for patients requiring surgical procedures which has led to the widespread adoption of this technique in many areas.  Secondly, the volume of patients receiving elective surgical care in the NHS has fallen considerably and a proportion of this work is now being undertaken in non-NHS hospitals.  

Both of these factors have had a significant impact on airway training for novice anaesthetists.  There is a risk that the cohort of doctors in training who are due to undertake the IAC in the coming year will be unable to gain sufficient clinical experience to develop the skills required for successful completion of the assessment.  This is particularly important for ACCS trainees, most of whom will only spend 6 months in an anaesthetic attachment.  Completion of the IAC is a mandatory requirement for this group and failure to achieve it within their anaesthetic placements will result in a requirement for additional training time and further impact training capacity in the future.

Measures to support training

The RCoA and DAS are working in partnership to produce guidance for both trainees and trainers to support effective training in airway management for those undertaking the IAC.  This will be available shortly via the DAS website.  In the meantime we would urge departments to consider the following areas:

• Ensuring that appropriate time is available for trainers and trainees.  This includes building time into both clinical schedules and also allocating sessions to support the use of simulation in the development of airway skills
• Establishing appropriate training facilities both in terms of accommodation and equipment to support the regular use of simulation as an adjunct to clinical practice
• Video laryngoscopy may be used as an alternative to direct laryngoscopy for training and assessment in endotracheal intubation in clinical settings.  However, trainees must also be able to demonstrate competence in direct laryngoscopy in simulated settings to achieve successful completion of the IAC

These measures are essential to support skills development in the current climate.  All departments should have a comprehensive plan to ensure that airway training can be optimised in the coming year to ensure successful completion of the assessments that form the IAC.