Human Factors in Airway Management

Key Points

Airway management occurs within the broad and complex sociotechnical system of healthcare delivery.
Aspects of design, training, and team functioning can be modified to improve safety.
Airway management is now a “team sport,” and interventions to improve safety should focus on team performance rather than individuals’ skills alone.
Explicit communication involving the use of cognitive aids and other checklists should be used in all nonroutine airway management episodes.
Improvements and safety should be addressed at a systems level with lessons from successes and failures distributed as widely as possible.

Introduction

Until relatively recently, the primary emphasis of efforts to improve success at airway management has been on the technical performance of the relevant procedural skills. In addition to requiring technical skill, however, airway management tasks often must be performed under time pressure with little margin for error while under threat of serious patient morbidity or mortality as outcomes. The varied circumstances of airway management in terms of patient variability, environmental differences, and team-related considerations mean that every airway management episode will be unique. These contextual factors can not only compromise the motor skills required for technical performance but may also impair cognitive performance, resulting in poor decision-making. ^, In recognition of this, attempts have been made to create standardized or “normative” processes for airway management, put into place to ensure that efficient completion of tasks with the widest possible margin of safety for the patient. Difficult airway algorithms, beginning with the first published failed intubation drill in 1976, are one example of this. Nonetheless, effective airway management, particularly in an emergency setting, requires much more than a clinician having the skills to perform a nominated task and a defined trigger for initiating them. Recognition that a trigger for performing an intervention has arisen depends on the relevant cues being evident, detected, correctly interpreted, and their implications understood. This, in turn, can be affected by factors such as the design and settings of monitors, the perception and attention of team members, and their experience and knowledge. When an individual other than the one responsible for undertaking the intervention recognizes a trigger, social factors, such as assertiveness and language, influence the effectiveness with which that information is communicated to the airway practitioner. Even once a trigger is recognized, the ability to access equipment in a timely manner will depend on use of language, how and where the equipment is stored and labeled, and the familiarity of supporting staff with these factors. The social aspect of airway management, and indeed of all other areas of healthcare provision, is commonly overlooked in theoretical descriptions of clinical care, but it is of vital importance in the practical performance of tasks. Airway management requires social interaction not only to coordinate the required physical tasks, but also for assessment, understanding, and trust of other team members’ skills. Airway management thus takes place within a complex sociotechnical system. Multiple interactions must occur between a minimum of two but often among several health professionals, as well as the patient, the equipment, and both a physical and an organizational environment.

The scientific field of human factors, or ergonomics, seeks to optimize the components and processes of complex systems to improve their efficiency and safety. Its focus is often misunderstood as being restricted only to nontechnical or teamwork skills such as leadership or communication. In addition to examining the interactions between clinicians, however, the field of human factors also addresses the interactions of clinicians with all the other elements in a system. A further misconception is that the science of human factors seeks to target the human element as the weakest link in the system. Although some human behavior can predispose to error, the adaptability of humans has the potential to greatly improve the ability of a system to operate safely under widely varying conditions. A well-designed system will both augment the ability of humans to enhance safe and effective performance and minimize the human vulnerabilities that contribute to errors. The field of human factors is multidisciplinary, bringing together diverse groups, such as engineers, architects, psychologists, and anthropometrists, to explore how clinicians behave and work in particular situations. The ultimate aim is to adapt the processes and equipment to support humans more effectively, with the consequence of providing safer and more efficient care. Put simply, human factors science is directed at making it easy for the team to “get it right.”

Over the past decade, there has been an increasing recognition of the significant contribution of human factors to the safety and effectiveness of airway management. In 2011, the Fourth National Audit Project of the Royal College of Anesthetists (RCoA) and the Difficult Airway Society (DAS) in the United Kingdom (NAP4) initially estimated that 40% of major airway complications involved human factors contributions. However, when a random subset of cases was examined in detail, all were found to have elements of failure at a human factors level related to task, planning, or communication with a median of 4.5 failures per case. The initial difference between these studies derives from appreciation of the scope of human factors beyond nontechnical skills. Human factors, in fact, contribute to the occurrence or severity of nearly all adverse airway events.

In order to conceptualize all the components in airway management and the complex interactions among them, a model, such as the extended Systems Engineering Initiative for Patient Safety (SEIPS 3.0), can be helpful ( Figure 12.1 ). The work system described in the SEIPS 3.0 model is typical of many other sociotechnical systems with interactions of people and technology, and it places the humans (“care team”) at the center of the work system. Careful attention to all aspects of the design of the work system can guard against failure of one component, such as the clinician managing an airway under time pressure. We will take each of these components and processes from the SEIPS 3.0 framework, in turn, to explain how human factors, or cognitive engineering, can improve safety and efficiency even in the face of extreme physiological compromise.

Fig. 12.1, SEIPS 3.0 model: sociotechnical systems approach to patient safety.

Components of Airway Management

Each of the components of the airway management sociotechnical system is interdependent. For example, the availability or introduction of new technology can affect how tasks are performed, who performs those tasks, decisions about when to perform them, and how the physical organization of the room can be optimized. When video-assisted laryngoscopy (VAL) was first introduced into clinical practice, clinicians quickly realized that it altered the optimal layout for equipment and that this may vary further, depending on where the display is located with different devices (i.e., a freestanding screen vs one attached to the laryngoscope handle). Furthermore, the ability of the assistant to see the screen augmented the contribution they were able to make to airway interventions (e.g., by providing improved external laryngeal manipulation). Consequently, this changed the teamwork dynamic between the assistant and the airway operator. As such, additional or modified training was required to account for the equipment, the different roles, and the different setups required when using a videolaryngoscope (VL). Thus, if the equipment to manage an airway changes, so must the task and the training for that task change with the new equipment. This is just one example of the domino effects of changing one element in an airway management system. Notwithstanding this, for clarity the following sections will address the components of airway management as if they were separate, but this underlying complexity must always be kept in mind.

Physical Environment

The physical characteristics of the environment in which airway management is performed greatly influence other components of airway management. Light, noise, and physical space are just a few of the potential factors that might adversely affect the completion of airway management tasks.

Any clinician who has performed an intubation in a prehospital setting knows that ambient light can be a complicating factor. Glare on screens or the impaired ability to see the airway structures due to the contrast and light adaptation of the eyes may hamper the ability to perform intubation.

Noise can make communications between airway team members difficult, impeding the coordination of tasks. As with lighting issues, noise is also a more commonly encountered problem in prehospital settings but can be an issue within healthcare facilities, in areas such as imaging rooms or other places where equipment without adequate sound shielding is used. Most often though, noise distraction results from other individuals talking during airway management procedures. Such noise tends to escalate during an airway crisis, further impeding clear communication when it becomes most crucial. Several solutions have been devised to minimize this. One technique borrowed from aviation is the “sterile cockpit” or “below-ten-thousand” rule. In commercial aviation, the usual procedure is to avoid all nonessential communication not directly relating to the task at hand when the aircraft is climbing or descending below 10,000 feet. These periods correlate with times of high workload, namely taking off and landing when distraction could be dangerous. Similarly, in medicine, the act of airway management could also be seen as a period of high workload or activity, when minimizing noise and distraction might theoretically improve communication and coordination. Attempts to enact the “sterile cockpit” principle have had mixed success, perhaps because of the awkward association with aviation and the terminology used. Alternative terms for the same strategy, such as critical period or focus, may have more success in the future.

The effect of the physical arrangement of the workspace on the ability to perform airway management is frequently underacknowledged. In the United Kingdom, it is common to anesthetize the patient in a separate anesthetic room adjacent to the operating room (OR). As noted, while this might minimize noise and distraction, it can also introduce additional complications such as the need to transfer an anesthetized patient into another room after an airway device has been inserted. Distractions from maintaining oxygen and anesthetic agent delivery during such times may occur, which might conceivably negate other potential advantages. Furthermore, equipment might not be easily available in the anesthetic room and surgical assistance might be slower and impeded by the limited space outside of the OR.

Airway management often occurs in environments, such as the emergency department or the intensive care unit (ICU), that might not be primarily designed for this purpose. As such, access for providers and to equipment for the patient's airway may be impeded—a phenomenon that may become compounded during a crisis as more staff and equipment are called upon to assist. Orienting monitors so that they are easily visible to the airway team may also become challenging in such environments. Increasingly, elective anesthesia is being conducted in locations, such as diagnostic imaging or cardiology rooms, where confined spaces are combined with bulky scanning equipment that also aggravates these issues.

With the combination of factors previously noted, it is not surprising that airway management in areas of the hospital outside of the OR is associated with higher risks of complications, such as death and hypoxic brain injury. Some estimates suggest these complications are up to 60 times more likely to occur in the ICU. The reasons for this are multifactorial, including patient factors and those related to training and equipment. However, it is easy to appreciate that airway management in environments that may be remote from additional advanced equipment and clinicians with advanced skills might be performed less favorably than it would in an area where expertise and equipment are concentrated. Many attempts have been made to address this, specifically the creation of difficult airway response teams (DARTs). These teams are similar in structure to cardiac arrest teams with preallocated roles and responsibilities and equipment that is taken to the location of the airway event. There is currently limited evidence of their effectiveness, but anecdotally they appear to improve outcomes of patients with complex airways in clinical areas outside of the OR.

Tools and Technologies

It is evident how the availability of different equipment might affect how airway management is performed. It may not be perceived as cost-effective to purchase expensive, specialized equipment (e.g., flexible intubation scopes; FISs) for environments where they are rarely used. However, inability to access required equipment derives not only from an absolute deficit, where the facility simply does not possess the equipment. Proximity, signage, presentation, and staff familiarity with storage locations may influence the ability to retrieve equipment within the required timeframe during an airway emergency. This once again illustrates the interdependence between different system components (organizational, physical, and individuals) in ultimately determining the availability of equipment. Equipment may also become unavailable due to damage, maintenance, or cleaning. This has become a greater issue with the increased use of more expensive and technologically advanced airway equipment, which may be purchased in smaller numbers and may be more vulnerable to damage. The increasing availability of disposable FISs and VL blades has somewhat mitigated these issues, but this solution comes at an environmental cost. Equipment deficits might also apply to more basic equipment, such as supraglottic airways (SGAs) through a simple failure to restock local stores. This may have implications beyond the lack of availability simply preventing immediate use of a device. In a study of 16 critical airway events, Schnittker and colleagues discovered that merely not having the equipment visible led to clinicians failing to consider that equipment as a potential option for rescue in five cases. Similarly, when equipment was available and its location was known, it helped prompt actions that enabled critical decisions. This demonstrates that clinicians may fail to request a device not present at the bedside, even though it could be retrieved from a remote location. Furthermore, equipment that is present may not be requested simply because a cluttered layout results in it not being readily visible. Decision-making is therefore not merely a product of training of the clinicians undertaking airway management but is also influenced by the context, environment, and prompts from equipment visibility. Historically, the difficult airway cart has typically been stocked with a multitude of specialized airway devices in an attempt to satisfy the needs of all clinicians and circumstances. More recently, however, a more restrained, strategic, and standardized approach to selecting equipment for the difficult airway cart has been advocated. The intent is to reduce clutter, improving visibility and simplifying decision-making in an emergency. Several researchers have also investigated the design of the difficult airway cart to ensure that it aligns with the decisions and prompts needed during an emergency. Typically, the drawers or compartments of a difficult airway cart correspond to specific equipment. Chrimes and colleagues described the “next generation airway trolley” as having a layout that aligns with the functions and decisions made during an airway emergency ( Figure 12.2 ). The ideal cart uses the same key elements as in the associated cognitive aid training and is standardized across all clinical locations. An alternative to this functionally based approach may be used in pediatric settings where equipment is grouped according to the size of the child. The equipment for routine airway management should be similarly organized such that performance in an emergency is familiar to reduce the stress and cognitive load of clinicians. A simple arrangement of the worksurface using a “kit dump” approach can be used. In this way, the key equipment that is required is presented in a clear and ordered manner and the omission of any item is immediately obvious. Ideally, the arrangement of the equipment on the surface aligns with the processes that are to be followed or are grouped in a logical manner. Work to determine how these surfaces should be arranged has already been undertaken using a codesign process based on simulation and feedback from clinical staff.

Fig. 12.2, (A) The Vortex Airway Rescue Cart is a dedicated emergency airway cart that uses a Vortex-based layout and icons. (B) In addition to prompting for the use of specific equipment, visual cues are used to prompt nonequipment-based interventions.

There are, of course, additional processes underpinning availability and usability of equipment for airway management that must be in place to ensure that the equipment is ready and serviceable when required. As noted, regulation of devices is needed to make sure devices are durable and fit for purpose. Furthermore, organizational arrangements must be made to safeguard the purchasing and upkeep of airway management equipment. An individual should be assigned this role in every organization.

Tasks

To a large extent, the tasks that must be performed during airway management are already predetermined with little scope for redesign. However, there are situations where revisiting the allocation of tasks within roles can be beneficial and a small amount of additional training might improve overall outcomes. For example, the role of the airway assistant in tracheal intubation has traditionally been limited to handing equipment to the practitioner performing the intubation. This arrangement developed because, until recently, the assistant was unable to visualize what the practitioner was seeing. The customary way to circumvent this was for the practitioner to verbalize what they were doing and seeing, and indeed this remains good practice. However, with the advent of VAL, there is an opportunity for the assistant to be more engaged and active in the process. With shared vision on the VL screen, the assistant is able to share the awareness of the practitioner and actively assist by external manipulation of the larynx toward the location of the tube. Furthermore, the experienced assistant can also make targeted suggestions and help guide decision-making under stress beyond vague suggestions such as “Would a bougie help?” as is commonly the case when visualization is otherwise limited. This is a good example of shared cognition. Rather than accepting that all of the perception, decision-making and monitoring of the situation must be performed by each individual, and relying solely on the leader who is often the operator, these functions can be assisted by other team members. As we will see later, sharing the cognitive load by using effective communication and cognitive aids can help prevent task fixation.

To establish other methods of performing tasks, human factors practitioners (ergonomists) commonly undertake task analyses. These task analyses take different forms, depending on the task and the purpose of the analysis. Hierarchical task analyses examine the detailed nature of the tasks required to reach the management goals. These analyses are useful for understanding physical tasks, such as intubation and the ordering and distribution of the tasks. Other forms of analyses might be more appropriate where information exchange and decision-making are central. Cognitive task analyses examine what information is required to make a particular decision and where that information is obtained. Task analyses can be useful when redesigning equipment and monitors and can guide how processes can be made safer and more efficient and where there may be gaps in training.

The appropriateness of task allocation may vary according to the situation. In a routine elective anesthetic setting, it would not be uncommon for the airway practitioner to also function in a leadership role, but as an airway crisis unfolds, assuming the dual role of leader and technician may become infeasible. A common problem in airway management in emergency situations is the loss of situational awareness. Loss of situational awareness, or “fixation error,” occurs when the team has failed to recognize the true nature of the situation and that solutions other than the solutions immediately available are required. As noted earlier, this might lead to repeated attempts at intubation or SGA placement beyond the number deemed reasonable by published guidelines. One of the roles that can be assigned to prevent this is that of a leader who does not get involved in performing other physical tasks but whose job it is to have an overall view of the situation. This can be problematic, as the leader in a difficult airway scenario is usually the most experienced in airway management, but in an airway emergency this person will usually be allocated to the airway practitioner role. Reframing the leadership role and renaming the person tasked with the overall view as the “coordinator” might remove this perception. This may allow a more junior member of the team or a nonmedical professional to adopt the role.

Team Members

The final component of the airway management work system are the people involved in performing the work—those centrally placed in the model. Health professionals must have specific characteristics to ensure that they can perform the work required of them during airway management episodes. Apart from the necessary professional qualifications and certifications, they must have undertaken specific training related to their roles. The training required can be described in terms of technical and nontechnical skills.

Technical skills include the physical actions required to perform an airway management task, such as the hand-eye coordination of laryngoscopy or flexible scope techniques. These tasks are easy to learn and best managed with a mastery approach to learning, where not just competency is achieved, but there is deliberate repetition with focused feedback on performance. In this way, the ability to manage novel situations under pressure is developed rather than a lower level of performance. Ideally, practice is spaced over time to enhance retention and includes situations with varying levels of complexity and difficulty in order to train to respond to different and adverse circumstances. Lack of confidence in specialized techniques may lead clinicians to find excuses to avoid performing them in favor of less safe practices, even when the former are clearly indicated. In several adverse airway events identified in NAP4, lack of confidence while performing awake tracheal intubation was thought to be a contributory factor in the decision to induce apnea and unconsciousness despite identification of a clearly difficult airway.

The cognitive skills required for airway management are commonly underappreciated. Even seemingly simple tasks, such as bag-mask ventilation, are complex cognitive tasks requiring detection of cues, processing of meaning of these cues, and adaptation. Observations of the visual scanning patterns of experienced clinicians performing infant bag-mask ventilation compared to novices are instructive. They demonstrated that experts rely on clinical cues in comparison to novices who rely on vital signs such as pulse oximetry that lag behind the immediate clinical picture of poor ventilation.

Decision-making is a key task of airway management teams. Teams must collectively gather information, evaluate potential options with their potential advantages and disadvantages, and plan for each technique. This planning often occurs in a time-pressured situation where information may be uncertain, and the situation evolves rapidly. Furthermore, teams must devise a strategy of how to move from one airway management technique to another, recognizing when one method has failed and must be abandoned, as well as how to and who should activate the next attempt. Contrary to common understanding, cognition is not dependent solely on what is occurring within a practitioner's mind but is an emergent property of the overall work system. As noted, cognition is affected by the positioning of equipment to prompt its use, suggestions offered by team members, availability and familiarity with cognitive aids such as mnemonics and algorithms to prompt a standardized approach, and the expertise and experience of individual clinicians. Decision-making and cognition are, therefore, an intangible amalgam of multiple factors rather than just knowledge and training.

Health professionals experienced in managing airways make decisions primarily by pattern matching to previous cases and situations, rather than by weighing the advantages and disadvantages of every potential approach. When teaching decision-making in airway management, emphasis should be on case-based discussions and the decision-making of experts. This may help novices develop decision-making skills vicariously from the cognitive processes of more experienced practitioners.

It also should not be forgotten that at the center of the airway management work system are the patients. Including the patient in decision-making is technically important for the technical purposes of keeping them calm and informed, as well as for the ethical and legal responsibilities related to consent. Truly informed consent is perhaps impossible in health care, and especially in airway management where procedures and decisions might be complex and difficult for a layperson to understand and weigh all the options. Nevertheless, explanation and inclusion are vital.

Organizational Conditions

Planning at the level of the healthcare service occurs at a higher level of management above the clinician is. The types of patients, staffing, rosters, and funding arrangements in each healthcare facility, such as clinics and hospitals, may have profound effects on the practice of airway management. There may be stark differences in the function of the hospital—such as whether pediatric, obstetric, or head and neck cancer surgeries are routinely performed there—which will invariably affect the way that the organization manages highly specialized activities. The organization also might play a significant role in ensuring that professionals in training are exposed to high-complexity cases and perhaps research to advance knowledge in subspecialty areas. In contrast, a more generalist facility may require distributed expertise and capability across a diverse range of clinical areas. The internal structure of the organization must be matched to these requirements.

Purpose

Depending on the clinical needs, emergency departments, ICUs, and ORs will schedule staff to specific activities. The scheduling must consider the skill mix and number of clinicians and ensure that staff are adequately rested, as clinical emergencies requiring airway assistance can occur day or night. It is self-evident that schedules and fatigue management systems which do not adequately account for the basic human requirements of the clinical staff will lead to impaired individuals who are less able to make effective decisions and perform clinical tasks to a high standard. Appropriate scheduling includes ensuring adequate breaks (and access to food and drink) during shifts, appropriate rest intervals between shifts, and judicious scheduling of overnight shifts. Despite the widespread availability of scheduling and fatigue management resources for clinical departments, it is still unfortunately common to have extended shift hours and patterns that contribute to both acute and cumulative sleep debt.

Funding

Funding is a substantial and ongoing problem in many healthcare systems. Even in high-income countries, the availability of VLs for every patient is still limited and thus a barrier to providing a core tool for the management of difficult airways.

In low-income countries, resources are extremely limited. Reuse of basic equipment such as latex gloves remains commonplace in these countries where the average daily income is less than $3 per day, and health spending is less than $50 per person per year. The provision of safe surgery and anesthesia in these countries has been aided by projects such as Lifebox, the Global Oximetry Initiative, and the Global Capnography Project. These charities provide pulse oximeters and capnography equipment to low-income countries in order to maintain minimum global standards for safe patient care. Although donations account for over 30% of health funding in low-income countries, these charities still provide less than 0.2% of health funding globally. Clearly, there is a disparity in provision of airway management between the richest and poorest countries, where the poorest third of the world's population has access to only 3.5% of surgery performed worldwide.

Culture

It is now well-established across many industries that the safety of patients (or workers/customers) and the safety culture of an organization are highly correlated. High-reliability organizations are always seeking incremental improvements in safety by learning about their previous performance and aiming to be better. This takes the form of two complementary mindsets: learning from failure and learning from success, commonly termed Safety I and Safety II . Safety II differs from traditional methods of larger-scale learning that concentrates on failures in the system and seeks to rectify them with regulations, more restriction, or education to change behavior. Thankfully, in the field of airway management the incidence of serious harm or death is now very low, but this makes it increasingly difficult to learn from failures. Furthermore, there is a disconnect between process and outcome. Poor process frequently will still result in good outcomes. Conversely, adverse outcomes may still occur despite best practice. As such, outcomes cannot necessarily be attributed to “good” or “bad” actions by the clinicians involved. By focusing only on the poor outcomes, the capacities of the individuals and the organization to learn are restricted. A true learning culture seeks to identify circumstances that successfully prevent or mitigate adverse events, even when the outcome is favorable. In the realm of safety science, the ability of a system to minimize or avoid adverse outcomes in the face of threats to patient safety is termed resilience . This term is starkly different when applied to individuals and their ability to cope with circumstances that are suboptimal.

The hierarchy within an organization is one aspect of safety culture directly affecting airway management. When individuals are able to speak up about events that they deem unsafe, they can avert clinical disasters. In many examples of death and injury from airway management, an inexperienced or junior member of staff speaking up may have prevented harm. For instance, merely pointing out that no end-tidal carbon dioxide tracing is present, that the oxygen saturations are not recovering, or that repeated attempts at tracheal intubation are against current guidelines and unlikely to be successful may lead an airway operator to attempt an alternative strategy, such as use of an SGA. A successful culture within an organization or clinical workgroup actively encourages questioning of senior members of the team.

Culture is developed over time by the actions of individuals performing the clinical work and by the managers who incentivize or reprimand specific behaviors that these individuals exhibit. Changing the culture of an organization is always difficult but can be accomplished over time by being consistent with regular education and reinforcement in the workplace. Such change requires a top-down approach. Leaders at the management and clinical levels should set an expectation for team members to speak up for the safety of patients or when they are uncomfortable with situations. Episodes of speaking up should be positively acknowledged and even rewarded to encourage this behavior.

External Environment

In terms of hierarchy, the external environment oversees the regulatory environment in which the health system and organization operate. The regulation and certification of the health professionals working within the healthcare system, the healthcare facility, and the equipment used are all required and relevant parts of developing a safe and effective system for provision of airway care.

The direct effects of the external environment on airway management became clear during the COVID-19 pandemic. Some areas of the world saw government policy and actions driving increased numbers of infections while simultaneously limiting supplies of personal protective equipment (PPE) . Clinicians who genuinely feared for their safety were compelled to adapt their techniques for airway management to address this lack of PPE by developing barriers intended to protect them from infectious aerosols generated during airway interventions. Acrylic “aerosol boxes” and plastic sheets created into makeshift tents around patients’ heads were disseminated and used widely. Approval of such devices by the Therapeutic and Goods Administration (a component of the external environment) through an emergency process condoned their use and implied that they were safe, which greatly increased their popularity. Subsequently, several studies have suggested not only that the level of protection provided by the boxes is much less than first expected but that they might actually increase the risk to the team managing the airway, with increased exposure and the risk of damage to their PPE . Furthermore, by impeding the performance of airway interventions, the risk to the patient is amplified. This failure of regulation arguably led to a detrimental change in the practice of airway management for many patients with COVID-19 during the pandemic. This is a clear illustration of how the external environment can influence the conduct of a clinical process and, consequently, how safe that process is.

Processes of Airway Management

The processes of airway management and how providers, equipment, and environment interact should be conducted in a way that ensures maximal efficiency and safety for the patient. Earlier versions of the SEIPS model included explicit reference to the processes that emerge from the components of the system, but these can be difficult to distinguish from the components themselves. Coordination of actions among healthcare providers requires a mutual understanding of the order of these actions. A well-coordinated team has a clear understanding of the clinical problems, the overarching goal, and how it will be achieved. This understanding requires a clear division of roles, an understanding of how each person's role fits into the whole procedure, and what will happen if certain obstacles or events are encountered. This understanding is collectively known as the “mental model” of the team.

A shared mental model of a problem and how it will be addressed is important to allow the team members to prepare themselves for their role and anticipate others’ needs. Furthermore, with a clear plan and expectation of how events will proceed, it is obvious to all team members if the airway practitioner or others become fixated on a particular solution. With a shared strategy comes implicit permission to challenge actions and reestablish situational awareness.

Explicit Protocols and Plans

Protocols are systems of suggested actions that help guide an airway management team under specific circumstances to progress through steps rapidly and comprehensively. Adherence to protocols allows for efficiently and robustly creating a shared mental model of a problem and the actions required. An example is an RSI protocol for a specified situation such as prehospital care, where the context and actions are well-defined. However, despite protocols being designed by experts for these generic circumstances, they commonly do not anticipate the specific problem faced by the practitioner. There will always be variations in the context, patient characteristics, pathology, and comorbidities that have not been foreseen by the expert group. Inevitably, modifications to the protocol must be made to suit the exact circumstances faced by the practitioner.

Tailoring the actions of a protocol to a specific clinical context means that the appropriate care can be delivered without the unnecessary or impractical steps of the protocol being included. A series of actions can be planned that are more efficient and context specific. For example, if a patient with limited mouth opening is being managed and the practitioner believes that an SGA cannot be inserted, this might reasonably be removed from the list of prospective options. The more specific the protocols, however, the greater the number of protocols that a clinical team must be familiar with and able to recall, which can increase cognitive load.

Other airway protocols relate to specific emergencies, such as the unanticipated difficult intubation. These protocols are designed as series of predetermined actions to be trained for and practiced so that performing them is as automatic as possible in case of a rare emergency.

Thus, these are the three levels of planned behaviors:

Strategies for individual patients (comprised of a coordinated combination of plans)
Protocols for specific (nonemergency) circumstances
Emergency protocols

All three types of preplanned actions must be clearly understood in detail by the airway management team. Which protocols and plans are followed may or may not be explicitly communicated among the team members at the time of the event. However, the team should be able to justify any deviation from the initial plan, such as when a piece of equipment malfunctions unexpectedly or the clinical picture changes.

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