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The evolution of a national, advanced airway management simulation-based course for anaesthesia trainees

Rewers, Mikael; Østergaard, Doris

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European Journal of Anaesthesiology: February 2021 - Volume 38 - Issue 2 - p 138-145
doi: 10.1097/EJA.0000000000001268



Although there has been an improvement in the rates of anaesthesia-related mortality, there is still room for improvement.1 Difficult airway management (DAM) is one of the primary challenges for anaesthesiologists and both inadequate knowledge and insufficient skills in using the equipment contributes to substandard treatment.2 Analysis of incidents has indicated that human factors are contributing factors in up to 80% of the incidents.3

Needs analyses of patient complaints and working anaesthesiologists’ confidence levels on DAM have indicated a need for training in both technical skills and non-technical skills (NTS).4–7 The NTS encompass cognitive skills (situational awareness and decision-making) as well as social skills (communication, leadership and collaboration).

Psychomotor skills such as flexible optical intubation (FOI) and cricothyrotomy can be taught effectively using advanced bronchoscopy simulators, simple airway manikins8 and high-fidelity simulation manikins.9 Several hospitals have developed local or regional airway management courses or training programmes for trainees.10–14 However, workshop-based airway training is variable in provision, frequency and content and is often not prioritised by departments or individual trainers. Hence, national guidance on airway management workshop organisation, frequency and content has been suggested by Jensen et al.15 A recent editorial in the European Journal of Anaesthesiology (EJA) has recommended a paradigm shift in airway management to focus more on human factors (including NTS), with a greater use of simulation training and based on the motto: ‘Humans come before tools, strategy before instruments and targets before devices’.16 Changing the way we conduct training programmes and implement new methods (e.g. simulation-based training) can be difficult. In surgery, advanced simulators have been available for more than 15 years, research has shown transferability of skills,17 but training is still not mandatory.18

However, the literature is limited on describing how to design a national, mandatory, simulation-based course in advanced airway management for anaesthesiology trainees.


In this article, we provide an example of how to design, implement and evaluate a national, mandatory, simulation-based course in advanced airway management for trainees within a specialist training programme encompassing medical knowledge, technical skills and NTS, using a broad range of learning and training methods, including simulations.

Design and results

The simulation-based course in advanced airway management

Anaesthesiologists’ specialist training lasts 5 years, consisting of an introduction year followed by 4 years of residency during which the trainees rotate through different subspecialties. The clinical training programme in Denmark is complemented by 30 mandatory course days financed by the Danish Health Authority. A national working group was established by the Danish Society for Anaesthesiology and Intensive Care Medicine with the overall objective of developing courses based on new educational methods. The working group included trainees, consultants responsible for clinical training, experts in advanced airway management, experts in simulation-based training, associate professors in medical education and the course director reporting to the Danish Health Authority. Hence, all stakeholders were involved from the start. In the following, we describe the design, implementation and evaluation process, as well as the evolution of the course over time, from the first course in 2003 until 2018.

Ethical considerations

Danish Law exempts this type of study from Ethical Committee approval as it does not involve patients. All trainees were informed and agreed that their feedback and test results could be used anonymously for further publication. The Educational Council of the Danish Society for Anaesthesiology and Intensive Care Medicine received the data in an anonymised form after each course.

The six-step approach

A six-step approach has been used. This is a practical and generic approach to curriculum development that can address present and future needs of learners and their medical institution.19 The six steps are: (1) Problem identification and general needs assessment, (2) Targeted needs assessment, (3) Goals and objectives, (4) Educational strategies, (5) Implementation, (6) Evaluation and feedback.

Step 1: Problem identification and general needs assessment

Significant increases in the number of patient complaints have indicated different requirements for physicians’ competencies. Therefore, a major reform of the postgraduate medical education in Denmark was initiated, including implementation of Competency-Based Medical Education. A new curriculum was developed including learning and in-training assessment strategies.

Step 2: Targeted needs assessment

Several studies have indicated challenges related to airway management.4–7 Patients died, or were harmed, due to health professionals’ lack of knowledge and practical skills in DAM.4,7 Data from the Danish Agency for Patient Complaints showed that in 10 out of 15 complaints intubation difficulties were not anticipated, preoperative airway assessments were not done routinely, an unsafe airway management technique was employed in patients with difficult airways and inadequate communication was demonstrated in several cases.4 A later study indicated that, potentially, four deaths could have been avoided by the extended use of airway algorithms, thorough preoperative evaluation and simulation training.7

A survey of anaesthesiologists’ knowledge and skills showed that less than 33% routinely identified the cricothyroid membrane when anticipating a difficult intubation and did not know exactly how to oxygenate via the cricothyroid membrane.5 Less than 50% performed awake intubation when expecting a difficult intubation, and among the specialists as many as 67% had little or no experience in FOI in awake/spontaneously breathing patients.5 Another study demonstrated that there was need for improvement in trainees’ knowledge and skills in DAM.6

Based on the results of the above mentioned studies of Danish anaesthesiologists’ airway management skills,4–6 Educational Committee of the Danish Society for Anaesthesiology and Intensive Care Medicine found it imperative to include education and training in DAM, including technical skills and NTS in the national, compulsory course to ensure trainees’ competence.

Step 3: Goals and objectives

The working group defined the overall goal and learning objectives of a new national mandatory course, based on general and targeted needs assessments. The overall goal of this course is to bring trainees’ technical skills and NTS in advanced airway management to a level that will increase patient safety. The learning objectives are grounded in the curriculum and the above mentioned needs analyses,4–7 representing knowledge, skills and attitudes (Table 1). The learning objectives also apply to several of the seven physician roles,20 including the NTS encompassing the cognitive and social skills necessary for safe and effective performance.21 Anaesthetists’ Non-Technical Skills, developed in the United Kingdom, were customised for the Danish setting and used as a basic framework to train and evaluate NTS.21,22

Table 1 - Learning objectives and the corresponding educational methods in the first national mandatory 3-day simulation course in advanced airway management (2003)
Learning objectivesAfter the session, the trainees should be able to… Method (no. of sessions)
Identify predictors of DAMDescribe the upper airway and neck anatomy and abnormalityDiagnose and manage a difficult airwayUse algorithm to manage an unexpected difficult airway Lectures (3)
Diagnose and manage a difficult airway in children Lecture (1)
Discuss possible airway techniques/strategies to prevent a difficult airwayDiscuss possible airway techniques/strategies for managing an unexpected or expected difficult airway Workshop (1)
Optimise positioning for securing the airwayHandle advanced techniques for airway management (FOI, intubation laryngeal mask airway and cricothyrotomy) Workshops (3)
Optimise positioning for securing the airwayDiagnose and manage a difficult airwayPrepare a plan for anaesthesia (including airway management)Use algorithm to manage an unexpected difficult airwayDiscuss possible airway techniques/strategies to prevent a difficult airwayPlan, be alert to and integrate information from monitors, clinical signs and operative interventionsEvaluate the difficulty and complexity of the case in relation to one's own resources and qualifications as well as the resources and qualifications of the local organisation, judge in cooperation with relevant parties, the need for expert assistanceStay calm and keep the overview, anticipate unforeseen events, initiate rational action to stabilise the patient's condition and systematically detect causes or errorsCommunicate appropriately with the team, utilise the human and technological resources appropriately, and call for appropriate assistance at requestManage teamwork effectively, and take leadership where this is appropriateShow ability and willingness for critical reflection of own actions, acknowledging unintentional incidents and possible errorsDemonstrate attention to the role and expertise of the anaesthesiologist especially in acute life-threatening situations and the professional responsibility this entailsContribute to individual and organisational learning and development Simulations with debriefing (3)
DAM, difficult airway management; FOI, flexible optical intubation.

Step 4: Educational strategies

The trainees receive precourse material including relevant literature and are asked to bring with them examples of real DAM cases. A variety of interactive training methods, such as skills training workshops and simulation-based scenarios followed by debriefings, are included. These provide a wide range of learning opportunities for the trainees allowing them to train in a safe learning environment where it is possible to repeat training until the desired learning objectives have been obtained (deliberate practise). Part-task trainers are used in the workshops, and manikin-based simulators are used in the simulations. Around 30 trainees participate in each course, which runs twice a year. Guided by a facilitator, the trainees work in teams of 5 to 6 to get as much hands-on experience as possible in 45-min sessions. Each trainee attends all course sessions.

The initial 3-day course was extended to a 4-day course. Since trainees are recruited from different university hospitals in Denmark, we introduced team building, as we recognised the importance for trainees getting to know each other before taking part in the training. This was an important part of developing a safe learning environment. The team building exercises have developed over time, from solving context-based tasks to preparing dinner together. Elements of the standardised course curriculum were refined over the years in response to the trainees’ and faculty's evaluation of the course. Table 2 shows an overview of the content and methods used in the 4-day course in 2018. All lectures are case-based and interactive, and conducted by experts in either pharmacology, education, DAM or allergology. Workshops covering situational awareness and decision-making, as well as social skills, are conducted by faculty members with a special interest in human factors. In the practical skill workshops, each trainee must perform hands-on training in various techniques (example in Appendix 1, Focus is on how to avoid and manage ‘can’t intubate, can’t ventilate’. The simulation-based scenarios are based on real-life clinical experiences covering different DAM situations (example in Appendix 2, In each scenario, two trainees manage the patient, whrereas the remaining trainees play the roles of surgeon, scrub nurse, circulating nurse or observer. The scenarios are followed by debriefing sessions or short feedback.

Table 2 - Overview of the content and methods used in the 4-day course (in 2018)
Day 1 Day 2 Day 3 Day 4
Welcome – introduction to the course Plenum Airway assessment and risk stratification Plenum Intubation under special circumstances (trauma, reintubation of patient in prone position, patient on floor) Workshop Simulation 7
Pharmacology – pharmacokinetics/dynamics Plenum Airway management – techniques, algorithms and strategies Plenum FOI 2 Workshop Debriefing 7
Pharmacology – drugs used for induction Plenum FOI 1 Workshop Simulation 1 FOI 3 Workshop
Neuromuscular blocking agents and monitoring Plenum Optimisation of intubation (including videolaryngoscopy) Workshop Debriefing 1 Emergency cricothyrotomy 2 Workshop
How to get the best out of my specialist education Plenum Airway cases – discussion with an expert Workshop Simulation 2 Anaphylactic reactions Plenum
Situational awareness and decision-making 1 Plenum and workshop Optimisation of facemask ventilation and pre/per-oxygenation Workshop Debriefing 2 OSCE rounds
Teambuilding exercises (e.g. preparing dinner together) Emergency cricothyrotomy 1 Workshop Simulation 3 and 4 (short) including feedback Situational awareness and decision-making 2 Plenum and workshop
Get Together dinner Optimisation of supraglottic airway (including intubation through this) and tube-exchanger Workshop Simulation 5 and 6 (short) including feedback Prepare your learning plan Plenum
Faculty meeting Faculty meeting Evaluation of the course Plenum
Faculty meeting
The plenum sessions are for all trainees simultaneously. Each trainee rotates through all the workshops and simulation sessions in groups of five or six. FOI, flexible optical intubation; OSCE, objective structured clinical examination.

Throughout the courses, there has been a strong emphasis on feedback and reflection on practice. The faculty members provide constructive feedback for the trainees in the workshops. In the debriefing sessions, the facilitators use questions to conduct a discussion of what happened in the scenario to help learners reflect on their strengths and weaknesses and to help them develop learning plans to improve future performance in both technical skills and NTS. The debriefing sessions are structured in three phases: description, analysis and application,23 where facilitators use specific questioning techniques.24,25

All simulation facilitators are specialised in advanced airway management and trained to conduct simulation/debriefing, and to establish a safe learning environment. Initial facilitator-training consists of a 3-day basic course followed by an additional 4-days advanced debriefing course. Recently, a faculty development programme was established. Each year, the facilitator chooses two courses covering topics within education and simulation developed by Copenhagen Academy for Medical Education and Simulation. In addition, the facilitator receives feedback based on video recordings of his/her debriefing practice and participates in a conversation on how to develop competence over the coming year. All simulation operators are certified anaesthesia nurses.

A course manual provides instructions for the facilitators, which makes it possible to standardise how the courses run. The faculty and curriculum developers use the information on the trainees’ strengths and weaknesses to improve future training. Recently, an e-learning programme in advanced airway management has been developed and implemented as precourse preparation to provide a foundation for the course and to help optimise knowledge retention, and to enable trainees to perform peer-to-peer technical skills teaching supervised by an airway expert.

The course is conducted in a state-of-the-art simulation centre in the Capital Region, featuring rooms fully equipped as operating theatres and with high-fidelity human patient simulators (Laerdal SimMan 2G/3G, Stavanger, Norway). Advanced airway management equipment is standardised in all rooms. The centre has the practical, technical and administrative staff needed to run the course. Resources are listed in Appendix 3,

Step 5: Implementation

National implementation has been facilitated by the working group members and opinion leaders from our society and the Danish Health Authority.

A total of 28 courses have been conducted between 2003 and 2018, and 800 2nd year trainees have participated. The courses have been adjusted over time in accordance with revisions to the national training curriculum and the difficult airway guidelines, the introduction of new airway management techniques, new knowledge about human factors and new training and assessment methods (timeline shown in Table 3).

Table 3 - Timeline for the evolution of the course
2003 Implementation of a national mandatory 3-day simulation-based course in advanced airway management for anaesthesiology trainees
2004 Extended to a national mandatory 4-day simulation-based course in advanced airway management for anaesthesiology trainees
2005 Implementation of a pre and postcourse test in DAM to optimise and adjust the course; we raised the level because 83% of trainees passed the pretest. More recently we have reduced the level of difficulty as the trainees now have less clinical experience
2008 Implementation of OSCE (only 7 stations for economic reasons); we introduced a formative assessment for learning (not summative assessment of learning) with immediate feedback in each station: there is no pass/fail, trainees make personal learning plans based on the feedback. The purpose is also to evaluate the effect of the course, therefore, it's not validated like a summative OSCE
2011 Implementation of short simulation sessions with immediate feedback to supplement the traditional simulations with debriefing
2012 Extended OSCE to 12 stations, still formative assessment for learning with immediate feedback in each station
2015 Development of an e-learning programme (adaptive learning) in advanced airway management
2016 Implementation of an e-learning programme as preparation and foundation, the purpose is to further optimise learning outcome from the 4-day course
2016 Implementation of a ‘Flipped Classroom’ in some of the technical skill workshops, where the assigned trainees, alternately, prepare their teaching by using the learning material in the e-learning programme and, supervised by an airway expert, teach the other trainees
DAM, difficult airway management; OSCE, objective structured clinical examination.

Initially, funding was insufficient, and the simulation centre was not reimbursed, the simulation facilitators were paid by their departments and the equipment was lent by companies. Now financial support from the Danish Health Authority is fully secured and the course organisers receive 1000 Euros per trainee for a 4-day course.

Step 6: Evaluation and feedback

We used Kirkpatrick's model in the planning of evaluation.26 In the first courses, the evaluations were at level 1 (‘reaction’ level) measuring the trainees’ satisfaction with the course to find out whether the course was at the right level of difficulty. An evaluation form including open ended questions with room for comments was developed for the purpose of modifying the course. On a 4-point scale, where 4 is best, only a few of the scorings were below 3. The trainees’ evaluation of the courses has been generally positive. They especially liked the comfortable atmosphere, good course organisation, great learning outcomes, professional facilitators and realistic simulations (better than theoretical lectures). Throughout the years, the trainees responses indicated that this course would modify their behaviour in DAM.

We evaluated at Kirkpatrick's level 2 (‘learning’ level) which measures the degree of change in learners’ knowledge, skills and attitudes.26 A pre and postcourse test was developed and completed at the beginning and the end of the course. The test consisted of nine questions on DAM: Five multiple answer questions, one Simplified Airway Risk Index score and three clinical vignettes (Appendix 4, A paired t test was used to analyse the theoretical test. A questionnaire addressing the trainees’ knowledge, experience and self-assessed competence regarding technical skills and NTS in DAM was developed and completed at the beginning and end of the course. It consisted of 21 questions: One question assessed overall confidence, eight assessed technical skills and 12 assessed NTS in DAM (Appendix 5, A 5-point Likert scale, where 5 is total agreement with the statements, was used. A Wilcoxon matched pairs test was used to compare pre and postcourse data. P values less than 0.05 were considered statistically significant. The theoretical test and the questionnaire were used on nine courses (2005 to 2010) including answers from 240 trainees. The theoretical test showed that the pass rate was 83% (199/240) and 96% (231/240) before and after the course, respectively (P < 0.001). It was clear that some of the topics were easy for the trainees and could be learned from reading the precourse material. Based on these observations, the course content was modified to spend more time on the content that was difficult for the trainees. Significant improvements were seen between pre and postcourse in the trainees’ self-assessment of all technical skills and NTS (Tables 4 and 5). The greatest improvements were seen in the technical skills statement: ‘I am able to use an emergency cricothyrotomy set’, and in the NTS statement: ‘I ensure that roles in the team are clear’.

Table 4 - Significant improvements in trainees’ self-reported technical skills were found when comparing pre to postcourse results
Statements (technical skills)‘I am able to…’ Precourse valuesMedian [IQR, range min to max] Postcourse valuesMedian [IQR, range min to max]
Perform a preoperative airway assessment 4 [4 to 5, 3 to 5] 5 [4 to 5, 2 to 5]
Use algorithm for airway management 4 [3 to 4, 1 to 5] 5 [4 to 5, 3 to 5]
Handle difficult facemask ventilation 4 [3 to 4, 1 to 5] 5 [4 to 5, 2 to 5]
Use intubation laryngeal mask airway 3 [3 to 4, 1 to 5] 5 [4 to 5, 3 to 5]
Use fiberoptic scope 3 [2 to 4, 1 to 5] 4 [3 to 4, 2 to 5]
Use emergency cricothyrotomy set 2 [1 to 3, 1 to 5] 4 [3 to 4, 2 to 5]
Perform awake fiberoptic intubation 2 [1 to 3, 1 to 5] 4 [3 to 4, 1 to 5]
Handle a ‘cannot intubate, cannot ventilate’ situation 3 [2 to 3, 1 to 5] 4 [4 to 4, 3 to 5]
Degree of agreement of the statements on a five-point Likert scale, where five is total agreement. IQR, interquartile range.P less than 0.001 () for all statements.

Table 5 - Significant improvements in trainees’ self-reported non-technical skills were found when comparing pre to post course results
Statements (NTS) Pre course valuesMedian [IQR, range min to max] Post course valuesMedian [IQR, range min to max]
I know my strengths and weaknesses regarding airway management 4 [4 to 5, 2 to 5] 4 [4 to 5, 2 to 5]
I have a clear understanding of the role of the team leader 4 [4 to 4, 2 to 5] 4 [4 to 5, 2 to 5]
I have a clear understanding of the role of an active team member 4 [4 to 5, 1 to 5] 4 [4 to 5, 2 to 5]
I ensure that roles in the team are clear 3 [3 to 4, 1 to 5] 4 [4 to 4, 2 to 5]
I prepare plans and make these clear for the team 4 [3 to 4, 1 to 5] 4 [4 to 5, 2 to 5]
I prioritise tasks according to level of importance 4 [4 to 4, 2 to 5] 4 [4 to 5, 2 to 5]
I inform the team of potential complications 4 [3 to 4, 1 to 5] 4 [4 to 4, 1 to 5]
I use clear communication 4 [3 to 4, 2 to 5] 4 [4 to 5, 2 to 5]
I use closed loop communication 4 [3 to 4, 1 to 5] 4 [4 to 5, 1 to 5]
I ensure that guidelines and plans are followed by the team 3 [3 to 4, 1 to 5] 4 [4 to 4, 2 to 5]
I re-evaluate the situation continuously 4 [3 to 4, 2 to 5] 4 [4 to 5, 2 to 5]
I receive input from the team in a constructive manner 4 [4 to 4, 1 to 5] 4 [4 to 5, 2 to 5]
Degree of agreement of the statements on a five- point Likert scale, where five is total agreement. IQR, interquartile range; NTS, non-technical skills.P less than 0.001 () for all statements.

Since 2008, the evaluation process has included an Objective Structured Clinical Examination (OSCE) at the end of each course. OSCE is an assessment of clinical competence undertaken outside the ‘real’ clinical environment. Aspects of workplace realism are incorporated into it and are assessed at the ‘shows how’ level of Miller's pyramid.27–29 The OSCE stations and checklists used to assess the trainees have been developed by experts (examples in Appendix 6, Each item on a checklist is scored on a three-level scale: ‘Good’, ‘Adequate’ or ‘Not done/Inadequate’. According to the Borderline Regression Method, the overall performance of the trainee is assessed as: ‘Clear fail’, ‘Borderline’, ‘Clear pass’, ‘Good pass’ or ‘Excellent’. As the intention is to stimulate learning, we use the OSCE as a formative assessment where the trainees receive immediate feedback at each station based on scores and narratives. It provides knowledge of what she/he has learned during the course, and what requires further training in the clinical environment. At the end of the course, the trainees prepare a learning plan that can be used for discussion with the consultant responsible for education in their workplace.


We successfully designed and implemented a mandatory standardised, national, simulation-based course in advanced airway management for 2nd year anaesthesiology trainees based on the six-step approach; to the best of our knowledge, this is the most comprehensive known course to date.

The course was successful due to thorough planning, selection of the most important learning objectives from the curriculum based on assessment of need, interactive educational methods, training of the facilitators and the involvement of all stakeholders. The course focuses on practical skills, airway management strategies and human factors and is in line with the thinking behind the Helsinki declaration on patient safety in anaesthesiology,1 strategies for prevention of airway complications,30 the principles of The Vortex Approach,31 and a recent Editorial in EJA.16

We introduced team building activities on course Day 1 to establish a safe learning environment where questions could be asked, and mistakes made without embarrassment (no-blame culture). Relationships were established between trainees as well as a common feeling of being in a team and solving tasks together. It was then possible for individuals to discuss different practices/strategies without feeling compromised or inadequate during the course. This is in accordance with recommendations by Sorbello et al.16

Education of the facilitators is paramount, especially in creating a safe learning environment, providing feedback to the trainees at the skills training workshops and OSCE stations, and in facilitating learning in the debriefings (after full-scale simulations). All our facilitators were experts in airway management, and they were all updated in new techniques in running scenarios and conducting debriefings over the years. The importance of facilitator training is in agreement with Krage et al.32 As in clinical training, faculty members’ development and maintenance programmes are crucial.32

We use low-fidelity simulators (part-task trainers) for technical skills training, and high-fidelity simulators for full scale simulations. Which types of simulators (high-fidelity or low-fidelity) to be used in simulation education is still unclear,33 but cost–benefit should be considered. The low-fidelity simulators are less expensive and if a learning objective can be obtained at a lower price we recommend low-fidelity simulators. This is in agreement with Green et al.34 who suggested that residency programs with financial constraints can use low-cost, low/moderate-fidelity simulators and still achieve comparable results to high-fidelity models. This is also in line with Krage et al.32 who emphasised that the level of realism lies in the experience the facilitator wants the participant to have. Studies evaluating whether high-fidelity simulators will provide additional educational benefits over low-fidelity models are needed.33

Results from the pre and postcourse tests and questionnaires indicate that the trainees’ knowledge increased as well as their self-assessed competencies in technical skills and NTS. Other studies evaluating mandatory simulation-based courses for anaesthetists report similar results.35,36

An OSCE has been incorporated into the Primary Fellowship of the Royal College of Anaesthetists (FRCA) Exam in the United Kingdom, and the Israeli Board Examination in anaesthesiology,37 both as summative assessments. Since 2008, the evaluation has included an OSCE at the end of each advanced airway management course in Denmark, but as a formative assessment where the trainees get immediate feedback at each station. We believe that assessment for learning (formative) is more important than assessment of learning (summative), as the constructive feedback will lead to improvement in learning and encourage striving for excellence, and thus achieve life-long learning. This is in agreement with Schuwirth et al.38 who gives a thorough explanation of what assessment for learning entails.

The trainees have been very positive in their feedback ever since the first course. This has given the already enthusiastic simulation facilitators further energy, which has reinforced their effort. Simulation has been successful because all simulation facilitators have been properly trained in building a safe learning environment and have been able to provide constructive feedback, and space for reflection.


Important factors for the successful implementation of the course were the establishment of a working group with broad national representation anchored in our national society, the enthusiasm of facilitators and the support from the heads of the clinical departments. Compared with other countries, the relative low number of departments responsible for training in Denmark makes it easier to implement national initiatives. In larger countries, such a course might be conducted at a regional level. One important factor facilitating the change was, that trainees already had mandatory (theoretical) courses. The needs analyses clearly provided the information as to why trainees should spend 3 to 4 days on airway management. The course had to be embedded within the existing courses, which had to be changed and content removed. Simulation-based training has several pedagogical and patient safety-related advantages: it provides a safe learning environment where the trainees can train without the risk of harming the patient, training can be adjusted according to the trainees’ needs, complex clinical challenges can be exposed and rare emergency situations can be trained for. Overall, the course complements the clinical training. In addition, the debriefing and feedback stimulate the trainees’ ability to reflect and help the learner learn how to learn.

According to Krage et al.32 simulation-based training of medical expertise skills, and team training, should be a mandatory component for anaesthesia residency programmes. Some countries provide simulation-based training in airway management for anaesthesiologists and trainees at a local or regional level.10–15 One of the benefits of a national course is that all trainees receive the same course content, independent of local guidelines and attitudes to airway management. Using the same facility makes it easier over time to invest in equipment to be able to run many sessions at the same time. Another advantage is that it is easier to adjust the course after each course evaluation. The challenge of keeping the simulation facilitators updated and on the same page is also easier. We conduct the training in a single simulation centre, but implementation at a national level in larger countries can be done by running the same standardised programme at several sites.

Discussion of the method used

We have used the six-step approach19 in the development, implementation and evaluation of a new course and found the concept very applicable. An optimal curriculum design is important to optimise the benefit of training.39 It is, however, important to consider curriculum development as a dynamic process. Progress is often made in several steps simultaneously as progress in one step influences progress in another. The course curriculum has matured over repetitive cycles of implementation. One major limitation is the use of a test without validating the scores. Finally, self-assessment of competencies is subjective and may be unreliable. However, the results have provided an indication of what was difficult for the trainees and on what we should focus. Since we had the information about learning, the use of theoretical tests and questionnaires was terminated and OSCE were substituted.

Future developments

Team training could be a follow-up initiative locally. This is in line with Baker et al.40 and Grande et al.,11 who suggest that lifelong learning in airway management should be seen as an ethical obligation for all anaesthesiologists, so as to keep up to date – not just trainees.

We have used an OSCE at the end of the course as a formative assessment. It would be interesting to evaluate if the skills could be transferred from the simulated to the clinical setting, and to evaluate the effect on patient outcome.


We successfully designed and implemented a simulation-based course in advanced airway management within the national specialist training programme. The six-step approach was valuable for designing the course. The evaluation of the course was very positive, and the trainees felt that the course was likely to change their practice. The course implementation was facilitated by anchoring the process in the National Anaesthesiology and Intensive Care Society and by the establishment of a national working group. Important factors for its success were thorough involvement of all stakeholders, a thorough design process, selection of the most important learning objectives, use of interactive educational methods, focusing on a safe learning environment and training of simulation facilitators.

Acknowledgements relating to this article

Assistance with the study: none.

Financial support and sponsorship: none.

Conflicts of interest: our simulation centre has received items of airway equipment for free. Neither the authors, nor their families, have any financial interest in any such company as far as they are aware.

Presentation: preliminary data for this study were presented as a poster presentation at the Scandinavian Society of Anaesthesiology and Intensive Care Medicine meeting, 15 to 17 June 2011, Bergen and at the European Airway Management Congress, 5 to 7 October 2017, Berlin.


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