Flexible Endoscopic Intubation in Emergency Medicine: A Needs Assessment

We conducted a needs assessment study to describe the current state of flexible endoscopic intubation in emergency medicine (EM) and to identify steps to improve education and practices related to this procedure. Flexible endoscopic intubation, a potentially lifesaving advanced airway technique, has been described in the EM literature for decades. However, it is rarely performed, and the literature discussing indications, frequency, and outcomes is limited. We recruited emergency physicians (EPs) in practice and training across varied settings to take part in a mixed-methods study incorporating focus groups and a targeted needs assessment survey. We organized three focus groups of community EPs, academic EPs, and resident EPs. We analyzed focus group transcripts by applying a constructivist grounded theory approach and generated codes and themes qualitatively describing the relationship of flexible endoscopic intubation to EM. The resulting codebook informed us during creation of our survey instrument, which we deployed in cross-sectional fashion. We report survey data with descriptive statistics. Thirteen EPs participated in our focus groups, and 257 EPs (33% response rate) responded to our survey, with 209 (26.9%) submitting completed surveys. Three themes emerged from the qualitative data: indications for use of endoscopic intubation, factors impacting a physician’s decision to endoscopically intubate, and attaining and maintaining endoscopic intubation competency. Most EPs (79%) received training on endoscopic intubation during residency; however, 82% of respondents had performed 10 or fewer in their career. Most (97%) felt they should have competency in endoscopic techniques, but only 23% reported a high level of confidence in their ability to perform the procedure on their own. A paucity of opportunities to perform endoscopic intubation in clinical settings was reported by 93%. Factors believed to facilitate acquisition of competency were opportunities to perform endoscopic intubation in practice (98%), local champions (93%), and performing nasopharyngoscopy (87%). Our results suggest that while most EPs believe they should possess competency in endoscopic intubation, many have a low degree of confidence in their personal ability to perform the procedure. We identify steps for improvement in education and the practices related to endoscopic intubation, including development of robust procedural curricula, support of local champions, and facilitation of nasopharyngoscopy use in the ED.