Understanding the Cognitive Demands, Skills, and Assessment Approaches for Endotracheal Intubation: Cognitive Task Analysis
Authors: Kunkes Taylor , Makled Basiel , Norfleet Jack , Schwaitzberg Steven , Cavuoto Lora 
Published: February 2022

Background
Proper airway management is an essential skill for hospital personnel and rescue services to learn, as it is a priority for the care of patients who are critically ill. It is essential that providers be properly trained and competent in performing endotracheal intubation (ETI), a widely used technique for airway management. Several metrics have been created to measure competence in the ETI procedure. However, there is still a need to improve ETI training and evaluation, including a focus on collaborative research across medical specialties, to establish greater competence-based training and assessments. Training and evaluating ETI should also incorporate modern, evidence-based procedural training methodologies.

Objective
This study aims to use the cognitive task analysis (CTA) framework to identify the cognitive demands and skills needed to proficiently perform a task, elucidate differences between novice and expert performance, and provide an understanding of the workload associated with a task. The CTA framework was applied to ETI to capture a broad view of task and training requirements from the perspective of multiple medical specialties.

Methods
A CTA interview was developed based on previous research into the tasks and evaluation methods of ETI. A total of 6 experts from across multiple medical specialties were interviewed to capture the cognitive skills required to complete this task. Interviews were coded for main themes, subthemes in each category, and differences among specialties. These findings were compiled into a skills tree to identify the training needs and cognitive requirements of each task.

Results
The CTA revealed that consistency in equipment setup and planning, through talk or think-aloud methods, is critical to successfully mastering ETI. These factors allow the providers to avoid errors due to patient characteristics and environmental factors. Variation among specialties derived primarily from the environment in which ETI is performed, subsequent treatment plans, and available resources. Anesthesiology typically represented the most ideal cases with a large potential for training, whereas paramedics faced the greatest number of constraints based on the environment and available equipment.

Conclusions
Although the skills tree cannot perfectly capture the complexity and detail of all potential cases, it provided insight into the nuanced skills and training techniques used to prepare novices for the variability they may find in practice. Importantly, the CTA identified ways in which challenges faced by novices may be overcome and how this training can be applied to future cases. By making these implicit skills and points of variation explicit, they can be better translated into teachable details. These findings are consistent with previous studies looking at developing improved assessment metrics for ETI and expanding upon their work by delving into methods of feedback and strategies to assist novices.