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Cricothyroidotomy In Situ Simulation Curriculum (CRIC Study)

Training Residents for Rare Procedures

Petrosoniak, Andrew MD; Ryzynski, Agnes RRT; Lebovic, Gerald PhD; Woolfrey, Karen MD

doi: 10.1097/SIH.0000000000000206
Empirical Investigations

Introduction Technical skill acquisition for rare procedures can be challenging given the few real-life training opportunities. In situ simulation (ISS), a training technique that takes place in the actual workplace, is a promising method to promote environmental fidelity for rare procedures. This study evaluated a simulation-based technical skill curriculum for cricothyroidotomy using deliberate practice, followed by an ISS evaluation session.

Methods Twenty emergency medicine residents participated in a two-part curriculum to improve cricothryoidotomy performance. A pretest established participant baseline technical skill. The training session consisted of two parts, didactic teaching followed by deliberate practice using a task-training manikin. A posttest consisted of an unannounced, high-fidelity ISS, during an emergency department shift. The primary outcome was the mean performance time between the pretest and posttest sessions. Skill performance was also evaluated using a checklist scale and global rating scale.

Results Cricothyroidotomy performance time improved significantly from pretest to posttest sessions (mean difference, 59 seconds; P < 0.0001). Both checklist and global rating scales improved significantly from the pretest to the posttest with a mean difference of 1.82 (P = 0.002) and 6.87 (P = 0.0025), respectively. Postcourse survey responses were favorable for both the overall curriculum experience and the unannounced ISS.

Conclusions This pilot study demonstrated that unannounced ISS is feasible and can be used to effectively measure cricothyroidotomy performance among EM residents. After a two-part training session consisting of didactic learning and deliberate practice, improved cricothyroidotomy skill performance was observed during an unannounced ISS in the emergency department. The integration of ISS in cricothyroidotomy training represents a promising approach; however, further study is needed to establish its role.

From the Department of Emergency Medicine (A.P.), St. Michael's Hospital; Division of Emergency Medicine, Department of Medicine (A.P.), University of Toronto; Sunnybrook Canadian Simulation Centre (A.R.), Sunnybrook Health Sciences Centre; Applied Health Research Centre (G.L.), St. Michael's Hospital, Toronto; and Division of Emergency Medicine (K.W.), University of Western Ontario, London, Ontario, Canada.

Reprints: Andrew Petrosoniak, MD, Department of Emergency Medicine, St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8 (e-mail:

The authors declare no conflict of interest.

The cricothyroidotomy kits were provided through an unrestricted grant by Cook Medical Inc, Bloomington, Ind, that had no role in the study concept, design, methodology, data analysis, or article preparation. This study was funded by the Department of Medicine Postgraduate Innovation Fund at the University of Toronto, Canada.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Simulation-based medical education (SBME) for technical skill training offers a possible solution for achieving competence in skills that cannot be acquired within the clinical environment. Essential to successful SBME is that it is integrated with deliberate practice,1 defined as repeated and structured practice by motivated individuals receiving feedback with the goal to achieve expert performance.2

In situ simulation (ISS), a training strategy that occurs within the actual clinical environment whereby participants may or may not be the actual clinical providers during their workday, is becoming an increasingly popular method to augment traditional laboratory-centered SBME.3 The value of ISS lies in its real-life applicability because it can enhance both environmental fidelity (the extent to which the simulator duplicates motion cues, visual cues, and other sensory information from the task environment4) and psychological fidelity (the degree to which the trainee perceives the simulation to be a believable surrogate for the trained task4).

Studies of ISS have highlighted its utility as a training strategy to reinforce desirable team behaviors among real team members, identify active and latent hazards within the clinical environment, and optimize equipment and ergonomics.5–9 The use of ISS for teaching rarely performed procedures may prove valuable given the positive effect on both environmental and psychological fidelity. An unannounced ISS for cricothyroidotomy training during an emergency department (ED) shift offers the resident both an opportunity to practice in their actual workplace and manage the ED demands that will be inevitable when they perform a real cricothyroidotomy.

This pilot study sought to evaluate the feasibility of a simulation-based technical skill curriculum for cricothyroidotomy using deliberate practice, followed by unannounced ISS during an ED shift. We hypothesized that it would be feasible to implement an ED-based unannounced ISS evaluation session after cricothyroidotomy training. Furthermore, we hypothesized that among EM residents, cricothyroidotomy performance would improve after deliberate practice when evaluated with unannounced ISS during an ED shift.

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Study Design

This study enrolled a prospective cohort of residents from the Royal College emergency medicine (EM) residency program at the University of Toronto. Participants underwent baseline cricothyroidotomy performance assessment (pretest) followed by a two-part training session (task-trainer session). This was followed by an unannounced ISS skill evaluation (posttest) during an ED shift 2 weeks later. The research ethics board of Sunnybrook Health Sciences approved this study.

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Setting and Population

The study was conducted at a University of Toronto–affiliated tertiary care hospital that averages 57,000 annual ED visits. All Royal College EM residents who had an EM rotation at the study institution between May 2013 and July 2014 were eligible and recruited (n = 21). Exclusion criteria included participation in any airway or trauma course within the previous 8 weeks.

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The intervention consisted of a two-part training session designed to improve cricothryoidotomy performance among EM residents using a percutaneous Seldinger technique (Melker C-TCCS-600; Cook Medical Inc, Bloomington, Ind).10,11 After written consent from each participant was obtained, all participants completed a baseline assessment (pretest) of their cricothyroidotomy skill in a simulation laboratory using a high-fidelity manikin (SimMan; Laerdal, Kent, UK). Two EM physicians with simulation expertise not affiliated with the study developed the scenario for each session. It was pilot tested for clarity, flow, and logistical considerations by EM residents not part of the study and modified accordingly. The scenario was a burn patient, which resulted in a “can't intubate, can't ventilate” situation requiring each participant to perform a cricothyroidotomy. The patient was hypoxic (SpO2, 88%), and the oxygen saturation decreased by 5% every minute. The scenario was designed such that all airway maneuvers were unsuccessful with the exception of a cricothyroidotomy and the scenario ended only after it was completed. A nurse confederate was present to assist and gather equipment.

The intervention training session, occurring 1 hour after the pretest, consisted of a didactic lecture followed by deliberate practice of a cricothyroidotomy using task-training manikins. For standardization purposes, the same instructor, an EM staff physician, conducted all didactic sessions and deliberate practice training. The didactic component addressed indications and contraindications to cricothyroidotomy, the technical aspects of the procedure, and performance improvement strategies. Participants watched video footage of simulated and actual cricothyroidotomies. Participants then engaged in deliberate practice for cricothyroidotomy performance with a task-training manikin identical in the head and neck anatomy to those used in the baseline and ISS assessment scenarios. The instructor provided task-specific feedback with each attempt. A successful attempt was defined as the “ability to ventilate, visualized by lung inflation.” The final attempt was video recorded and timed. The final attempt occurred once the participants felt comfortable with all necessary steps and the instructor agreed. This occurred after a minimum of five successful attempts based on evidence to suggest five is the minimum experience for a plateau in performance time (PT).12 If the participant did not successfully complete the procedure during their final attempt, they received additional task-specific feedback from the instructor along with deliberate practice to address the area of difficulty. An additional attempt was video recorded, timed, and analyzed. The participants were told the study concluded upon completion of this session.

Two weeks later, after each participant completed the task-training session, a surprise ISS was conducted in the ED (posttest). To enhance the psychological fidelity of the ISS, it was kept secret from the participant. Only the ED charge nurse and supervising ED physician were notified in advance. A “stat” call was made for the participant to attend a patient room in the ED. A high-fidelity manikin was set up with full monitoring capability (electrocardiogram, blood pressure, SpO2, ETCO2) and airway equipment in the designated ED room. To facilitate technical skill performance comparison with session 1, the simulated case differed only by patient sex, age, and circumstances causing the patient's burn.

A formal debriefing was conducted with each participant by a study investigator with formal debriefing expertise (A.P.) after both the pretest and posttest. Debriefing focused on emergency airway management and decision making with specific attention to the technical skill performance of a cricothyroidotomy. All simulations during the pretest and postest and the final successful attempt during the task-training session were video recorded for blinded review.

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Technical Skill Performance

The primary outcome was the mean difference in cricothyroidotomy PT (measured in seconds), between the pretest and posttest because this closely resembles “real-life” scenarios. Additional a priori comparisons included the PT between the task-trainer session and both the pretest and posttest to address immediate learning and skill translation to the clinical environment, respectively. There is no standard convention for measuring cricothyroidotomy PT, so using previously published criteria, it was defined from when the participant grasped any kit equipment until successful ventilation.13 The proportion of residents who completed a cricothyroidotomy in 100 seconds or less was also compared, a time limit based on a review of studies using the same kit and the deleterious physiologic considerations of a prolonged procedure.13,14

Additional performance metrics were assessed using a previously validated task-specific checklist (CL) score and a global rating scale (GRS).13,15 The CL (see Appendix A, Supplemental Digital Content 1,, a maximum score of 10, was used to measure the completion and performance of each critical step, whereas the GRS (see Appendix B, Supplemental Digital Content 2,, a maximum score of 35, measured participant performance using general descriptors. Two independent evaluators with extensive simulation experience scored the videos using the CL and GRS. Both evaluators were blinded to the study outcome, the order of the videos, and each other's scores. Both evaluators were trained by the study investigator (A.P.) to ensure standardization. All steps of the CL and GRS were reviewed, and each evaluator watched and rated a video-recorded cricothyroidotomy performance for further clarification. The intraclass correlation to evaluate the interrater reliability for both the CL and GRS by comparing the scores of twenty randomly selected videos scored by both reviewers, on the basis of a sample size calculation for interrater reliability.13

Participants completed a prestudy questionnaire that included demographics, comfort, and experience with a cricothyroidotomy in both real life and simulation. A poststudy questionnaire included identical questions to evaluate the impact of the training program.

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In situ Simulation Feasibility

Immediately after the posttest, the EM staff physician supervising the resident during the shift was surveyed (see Appendix C, Supplement Digital Content 3, The impact of resident absence on patient care and staff physician perception regarding ISS was assessed. All participants completed a questionnaire regarding their attitudes and opinions about the curriculum and the ISS. Total time for the ISS session was measured from the time the resident was called to the ISS until the debriefing was completed (see Appendix D, Supplemental Digital Content 4, Delays and cancellations were also tracked.

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Statistical Analysis

Demographic data and survey were analyzed using descriptive statistics. The PT mean differences between sessions, the CL, and GRS were compared using paired Wilcoxon sign rank tests and paired t tests for nonnormal and normally distributed data, respectively. Paired proportions were analyzed using McNemar tests to account for the correlation within matches. The primary outcome investigated the mean difference in PT between the pretest and posttest. Secondary analyses compared the mean PT between each of the pretest, task-trainer session, and posttest. The primary outcome used a two-sided significance level of 0.05, whereas secondary analyses were performed without correction for multiple testing. The subject who did not complete the posttest was removed from analysis related to the ISS but was included in the other comparisons. A sample size of 20 subjects provided 99% power to detect a mean paired difference of 60 seconds using a two-sided paired t test with a significant level of 0.05. Statistical analyses were performed using SAS Version 9.2 (Cry, NC).

Study funding was provided by the Department of Medicine Postgraduate Innovation Fund. All cricothyroidotomy kits were provided by Cook Medical Inc, which had no role in the study concept, design, data analysis, or article preparation.

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Twenty residents took part in the study and nineteen completed the pretest, training intervention, and posttest. One resident did not complete the posttest because of illness. Participant baseline characteristics are summarized in Table 1. Only one resident had ever performed a real-life cricothyroidotomy, whereas five residents had performed a cricothyroidotomy during a high-fidelity simulation although none occurred in the preceding 6 months.



In the primary outcome analysis, only participants who completed both the pretest and posttest (n = 19) were included. There was a significant improvement (P < 0.0001) in the mean PT (60 seconds; 95% confidence interval (CI), 33.9 to 86.0) between the pretest (158 seconds) and posttest (98 seconds), as depicted in Table 2 and Figure 1. There was a significant improvement (P < 0.0001) in mean PT (78 seconds; 95% CI, 55.5 to 100.3) between the pretest and the task-trainer session. The mean PT slowed significantly (P = 0.001) between the task-trainer session and the posttest (−18.6 seconds; 95% CI, −28.9 to −8.4). The proportion of residents who completed the procedure in less than 100 seconds increased significantly from 11% (2/19) in the pretest to 63% (12/19) in the posttest (P = 0.0016).





The CL and GRS scores are summarized in Table 2. From pretest to posttest, the mean scores for the CL (mean difference, 1.82; P = 0.002) and GRS (mean difference, 6.87; P = 0.0025) improved significantly. The intraclass correlation level of agreement for the CL was 0.44 (fair to moderate) and 0.62 (good) for GRS, whereas the correlation was 0.47 and 0.77, respectively.16 The study sample size precluded analysis of the impact postgraduate year (PGY) level had on performance.

The feasibility of the ISS portion of the study was also evaluated. The mean ISS and the mean total posttest time (combined simulation and debriefing) were 6 minutes 22 seconds and 16 minutes 55 seconds, respectively. The average combined set-up and take-down time was 32 minutes. The ISS session was delayed for two participants (23 and 35 minutes) because of resident participation in the resuscitation of a critically ill patient.

All EM staff physicians supervising participants on shift during the ISS session were surveyed. There were no reported instances during the resident's absence, whereby the staff physician intervened on patient care issues that would have been managed by the resident. In one instance, the resident was called away while suturing; however, the patient expressed no concerns regarding the interruption. Most surveyed staff (18/19) felt that the resident absence for ISS did not negatively impact patient care. Furthermore, 89% of staff (17/19) agreed or strongly agreed to regular ISS during a shift. Few staff (3/19) reported potential concerns that ISS may be disruptive during higher volume periods; thus, sessions during these times should be avoided.

Participants completed precurriculum and postcurriculum surveys, with 100% (n = 20) and 95% (n = 19) response rates, respectively. Participant comfort performing a real-life cricothyroidotomy did not change significantly (P = 0.09) between the precurriculum and postcurriculum evaluation. Additional participant attitudes on task-training and ISS for procedural skill acquisition are detailed in Figure 2. Most participants (95%) reported their willingness to participate in future procedural skills training that included unexpected ISS.



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Historically, technical skills training in residency occurred at the bedside using the “see one, do one, teach one” approach.17 Trainees relied on chance clinical encounters to gain adequate exposure to learn a range of required technical skills. Medical education has recently undergone a paradigm shift toward competency-based education whereby trainees must now demonstrate documented proficiency in clinical skills through outcome-focused objectives.18,19 Consequently, residents must achieve technical skill competence through alternative means rather than rely on real-time opportunities. Simulation-based procedural skill education has emerged as a feasible alternative that may positively impact patient outcomes.20,21 Simulation has become particularly important for technical skill acquisition of rare procedures because of the lack of actual clinical opportunities, although best practice recommendations for curricula are lacking.22

In this study, we describe the novel application of ISS to evaluate cricothyroidotomy performance among EM residents after a two-part training session for this rare procedure. Residents demonstrated significant improvements in cricothyroidotomy performance within the clinical environment using ISS compared with a pretest laboratory-based simulation scenario across time-based measures (PT) and objective assessment scores (GRS and CL scores). This study serves as a pilot for the integration of ISS as a feasible technique for training programs that teach rarely performed procedures.

Studies of technical skills frequently focus on the following specific outcomes: participant comfort,21 assessment tool validation,23 or technique comparison.14,24 In contrast, this study applied deliberate practice, a technique critical to SBME success,1 followed by the assessment of skill performance within the clinical environment. Deliberate practice for technical skill training is designed to achieve “constant skill improvement, not just skill maintenance”1 through directed and focused feedback. Residents received individualized feedback and successfully completed at least five cricothyroidotomies on a task trainer, a minimum number associated with a plateau PT.12 This training resulted in nearly a 50% reduction in PT compared with pretest performance (157 s vs. 79 seconds, P < 0.001).

Experts have advocated that deliberate practice should be followed by the incorporation of the task in a more complex environment to enhance skill development.2,22 This approach first promotes the consolidation of the techniques needed to perform the skill. Additional complexity is added by translating skill performance to the clinical environment whereby the participant must negotiate both the challenges of the skill itself as well as the distractions present in the clinical context.25 The application of ISS to enhance the situational context for technical skill evaluation is novel and may represent an important approach particularly for rarely performed, high-stake procedures such as a cricothyroidotomy. In this study, during an ED shift 2 weeks after the deliberate practice session, participants performed a cricothryoidotomy in an unannounced high-fidelity ISS significantly faster (157 vs. 98 seconds, P < 0.001) than during a nearly identical pretest scenario. Interestingly, the PT did slow from the task-trainer session to the ISS posttest. This may be explained by the focus of the deliberate practice on successful task completion rather than explicit performance standards (eg, target PT). If residents had been trained to meet prespecified performance standards, a characteristic of mastery-based learning,26 more durable skill performance may have been observed. Skill decay more than 2 weeks and the impact of a high-stress, high-fidelity simulation on skill performance may have also contributed to this observed increase in PT.27 The systematic integration of ISS, however, in technical skills training may serve as a central element in skill training for rarely performed procedures.22

The main challenge in teaching technical skills using simulation is proving that simulation-based performance improvements will translate to clinical practice particularly during a high-stress, high-stakes situation. Patient-oriented outcomes have been evaluated in several simulation-based procedural skill studies,28–31 yet such evidence remains elusive for rarely performed technical skills. Educational researchers have been called upon to move beyond participant-oriented outcomes such as posttraining questionnaires and instead address how the educational intervention can positively impact patient outcomes.32 This is exceptionally difficult for a cricothyroidotomy educational intervention given that most residents will never perform nor even observe the procedure during their training.33–35

To bridge the gap between simulation-based and patient-oriented outcomes, this training program integrated ISS. Performance during an unexpected ISS is more comparable with real life than planned laboratory-based simulations. Although all simulations are undeniably different from real life, ISS profits from both enhanced psychological and environmental fidelity, features often lacking with task trainers or even high-fidelity laboratory-based simulation. Attention to the situational context for technical skill performance is supported by the principles of situated learning theory, which suggests that learning is tied to the context of the experience.36 By incorporating training within the actual workplace, learners benefit from context-specific skill acquisition, a key component of simulation-based procedural skills education.25 During the ISS session, the equipment and room set up were identical to that used in an actual resuscitation. Environmental fidelity was further enhanced with the various distractors that exist within the ED (eg, noise, interruptions). In situ simulation also improves the psychological fidelity of a scenario. Participants were called away from their immediate clinical duties, forcing them to balance ongoing patient responsibilities with the decision making associated with an unexpected airway catastrophe. Although it was beyond the scope of this study to evaluate the psychological impact of an unexpected ISS, most participants agreed that the unexpected ISS was an anxiety-provoking experience. Further study is needed to evaluate the extent of the stress response elicited and how unexpected ISS can mimic real-life decision making.

In situ simulation is not an educational panacea. It is a training strategy that has both obvious strengths and weaknesses.3 In situ simulation should be carefully applied given its resource intensity and potential impact on actual patient care because clinicians are drawn away from clinical work. In this study, several supervising staff physicians reported concern that ISS may be disruptive during high volume periods, highlighting the need to appropriately plan these sessions to ensure that patient safety is not at risk when staff resources are overwhelmed with patient care. For procedures such as central venous catheter placement, ISS is unlikely needed given the high frequency of real-life opportunities.37 The value of ISS lies in its real-life applicability allowing trainees to practice procedures rarely performed in the clinical environment. Not only does this provide an opportunity to gain familiarity with the team and equipment, but also may trainees benefit through enhanced psychological fidelity by operating under unexpected circumstances. In the postcurriculum survey, all participants reported that they enjoyed the unexpected ISS experience and that additional unexpected ISS for procedural skills training should be integrated into their residency training. This study offers a promising instructional design by applying ISS for the evaluation of rare procedures.

Importantly, the findings from this study suggest that the integration of ISS into regular EM shifts seems to be feasible. With specific, focused objectives, ISS for cricothryoidotomy training with a structured debriefing can be conducted in less than 20 minutes with an additional 30 minutes needed for set-up and take-down. Appropriate planning is required, however, to ensure that an ISS will not negatively impact patient care by pulling resources away from other clinical areas.

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This study has several limitations. Because there was no control group due to ethics limitations, we cannot conclude that this curriculum is the only effective approach nor can we precisely identify causality for performance improvement. However, our results are strengthened by the use of established training strategies including deliberate practice, which are superior to traditional methods in SBME.1 Further study should be sought to clarify our findings with a randomized trial comparing this curriculum followed by ISS with conventional training and laboratory-based simulation evaluation. All participants were from a single Canadian EM residency program. A multicentered study would render these results more generalizable; however, participants were from all PGY levels and their precurriculum cricothyroidotomy experience was similar to published reports.33,35 The study design did not allow for conclusions regarding skill retention beyond 2 weeks. Future study is warranted to evaluate whether this curriculum would result in superior retention as compared with alternative training programs. Finally, this study evaluated only skill performance using the Melker kit, which was selected given the well-studied evaluation tools (eg, CL and GRS) and its use within our institution. The strength of this study is the ease in which any technique (eg, scalpel-finger-bougie) could be substituted because this study applies well-established training techniques.

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This pilot study used unannounced ISS to evaluate the cricothyroidotomy performance by EM residents after deliberate practice. Participants demonstrated significant improvement in time- and score-based outcomes for an emergent cricothyroidotomy during an unannounced ISS compared with a pretest session. In situ simulation proved to be a feasible and measurable technique for realistic cricothyroidotomy training in an EM residency. Further study is required to the effectiveness of ISS compared with laboratory-based simulation training for procedural skills training.

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The authors thank Glen Bandiera, Jordan Tarshis, Melissa McGowan, and the Sunnybrook Canadian Simulation Centre for their integral support for this study. We also thank the ED staff at Sunnybrook Health Sciences Centre for their support during the in situ simulation sessions.

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In situ simulation; Cricothyroidotomy; Procedural skill; Postgraduate

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