A report on virtual ‘Can’t intubate,can’t oxygenate’ conference workshops at the 2021 Annual Scientific Meeting of the Australian and New Zealand College of Anaesthetists

Introduction

The COVID-19 pandemic has disrupted the ongoing education of health professionals globally. Travel restrictions, border closures and lockdowns have made the planning and execution of conferences near impossible, with most being postponed or cancelled.^1,2 Preparation for the Australian and New Zealand College of Anaesthetists (ANZCA) Annual Scientific Meeting (ASM) has a long lead time, with planning for the 2021 ASM in Melbourne beginning in June 2019. As preparation was underway, the COVID-19 pandemic unfolded, and the 2020 ASM, in Perth, Western Australia, was cancelled. Uncertainty about the progression of the pandemic meant that the 2021 ASM organisers planned for both virtual and face-to-face programmes. While Australia and New Zealand have fared better than many parts of the world during the pandemic, the shifting landscape regarding snap lockdowns, Australian interstate border restrictions, the potential for an Australian and New Zealand ‘travel bubble’, and vaccination availability led to the decision in October 2020 for a virtual-only ASM.

While most traditional lecture-style presentations have successfully been converted to online platforms as the pandemic has progressed,^3,4 smaller group workshops, in particular those concentrating on technical skills training, have met greater hurdles.

The Monash Medical Centre airway group was approached in planning infancy to deliver a version of its ‘Can’t intubate, can’t oxygenate’ (CICO) workshop (comprising pre-reading, lecture and dry- and wet-lab components ⁵ ) for ASM participants. When it became clear that the ASM would be delivered virtually, organisers and workshop facilitators worked together to plan for a viable virtual CICO workshop. International colleagues with a special interest in airway management were approached to ascertain if anyone had previous experience delivering a virtual workshop, and while one group had experience with a hybrid-style technique, none had delivered a fully online workshop. The major hurdles to providing a virtual CICO workshop were delivering an adequate dry-lab airway kit to participants, the technical requirements to enable clear audiovisual (AV) connections during the session, and meeting strict criteria mandated by the ANZCA to ensure a high-quality and economically viable offering was approved for continuing professional development (CPD) purposes. ⁶ As there was little international experience to draw on, we report our experience here in the hope that it will help future groups attempting similar ventures.

Preparing for workshop delivery

An inventory of components required for a CICO kit was compiled and sourced from either existing ANZCA stock or new orders via hospital and commercial suppliers. This was based on the exact CICO kit used in all critical care areas across the Monash Health network (a public health network composing of six hospitals in Melbourne’s south-east). Three-dimensional printing of larynxes was undertaken via a commercial printer with specification of a biodegradable plastic made from cornstarch (with prototypes tested to make sure the model was robust). The 3D model used for the larynx was generated from the open-source file available on the Airway App site–an international collaboration that crowdsources data on failed airway events and provides resources for training (www.airwaycollaboration.org%2F3d-cric-trainer-1). ⁷ With the lower costs of a bulk order, the unit cost was approximately A$16.00.

Wooden bases for the larynx model were prepared by a facilitator with woodworking skills. Kits were assembled and posted out to participants six weeks ahead of the workshop. Appendix 1 shows the components of each CICO kit delivered to participants (Figure 3). Accompanying the CICO kit was an information sheet outlining components included in the pack, along with instructions regarding the virtual setup, recommending a laptop with inbuilt camera elevated on books or a separate webcam connected to a computer to provide a more flexible solution. Further information was given regarding a planned technical check-in time with the conference audiovisual team a week prior to the workshop, with an emailed meeting request sent to participants.

Contents of the session

The 48 participants were split into three groups of 16 participants per 90-minute workshop, with three facilitators in the central studio and four facilitators at home in their AV hubs. Each workshop commenced with a live interactive lecture with accompanying PowerPoint presentation delivered from the central hub at the convention centre using the Zoom® (Zoom Video Communications, San Jose, CA, USA) platform. Pauses were allowed for questions from participants (usually raised via the chat function that was scanned by one central facilitator), with a subsequent planned clinical scenario discussion and then a live demonstration of emergency front-of-neck access (eFONA) techniques, including cannula and scalpel-bougie techniques. Multiple camera angles were used throughout this demonstration. Particular emphasis was placed on the pitfalls of each procedure, on the jet oxygenation technique using the Meditech Rapid-O2® (Meditech Systems APAC, Perth, Western Australia) insufflation device (this was delivered as part of the CICO kit with acknowledgement that most participants would not have access to an oxygen cylinder and so could not experience the feedback given if there is obstruction to flow in an inadequately placed cannula), and on the conversion of a cannula to a Melker Emergency Cricothyrotomy Catheter Set (Cook Medical LLC, Bloomington, IN, USA). This was followed by Zoom breakout groups with a maximum of four participants per instructor, facilitated remotely for the hands-on dry-lab component where participants were able to practise their skills under scrutiny. A worksheet for facilitators was developed to check that participants met the requirements for each technique. The last five minutes of the workshop saw all participants return virtually to the central hub for a debriefing session and final question time.

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Figure 1.

Schematic representation of the cameras and setup for each facilitator and presenter.

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Figure 2.

(a) Facilitator’s home studio setup for teaching of the workshop, showing ring light, elevated laptop and separate webcam. (b) Facilitator’s home setup for teaching of the workshop with ‘can’t intubate, Can’t oxygenate’ kit components.

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Figure 3.

Components of the ‘Can’t intubate, can’t oxygenate’ kit as listed in Appendix 1.

A pre-workshop survey was delivered to participants via email a week before the workshop with a reminder email two days prior, with questions ranging from demographics and AV, internet and equipment setup to participant motivations and expectations of the course. A post-workshop survey was emailed to participants at the conclusion of their workshop with a verbal request to complete, and then a reminder was sent two days later. The post-workshop survey was designed to seek answers to the facilitators’ specific research questions such as whether learning objectives were clearly set out, whether these objectives met, how the workshop compared to participants’ expectations, and whether there were hurdles to the delivery of the workshop (especially logistical). Also sought were further insights into perceived advantages and disadvantages of the workshop and suggestions for improvements for future workshop delivery. As the responses were anonymous, circulated as voluntary and related solely to the conduct of the workshop, this was deemed an education quality assurance activity, and formal approval through an ethics committee was not sought. Surveys are available in the Supplemental Material.

Facilitators’ experience of the workshop

Only 10/48 participants attended the scheduled technical check online a week prior to the event. While participants were given an instruction to log on 30 minutes prior to the starting time, most attendees arrived five minutes before starting. While the central hub AV staff were quick to deal with each attendee as they logged in (often only needing to change an attendee’s camera angle, model orientation or lighting), this did impact workshop starting time and meant a slightly delayed finish.

All breakout room facilitators purchased extra equipment such as high-definition webcams and ring lights prior to the workshop (initially this was not standardised, but after the run-through the evening prior, one facilitator went out to purchase a webcam on noting their setup was inferior). We found the breakout rooms were quickly deployed by the central AV hub team, minimising delays in commencement. Prior to each session, the CICO kit was reset, with new skin surfaces attached using removable staples. A repeat demonstration of each technique was followed by sequential performance by the participants in a random order. The demonstration included commentary on potential pitfalls and strategies to mitigate or overcome these. One benefit found was that remaining participants were able to observe each other’s attempts closely along with the facilitator, reinforcing feedback on the techniques and allowing for further questions and comments based on observed outcomes. While facilitators were initially concerned that correcting technique virtually might be more challenging, asking the participant to slow their actions and talk through each step of each procedure allowed participants’ technique to be clearly demonstrated. Each session involved casual discussion around personal experiences with CICO, and in most of these breakout groups, facilitators found the discussion flowed well. All facilitators reported they encouraged participants to take the workshop’s dry-lab learning further. Discussions included strategies to conduct local CICO training in their workplace using the 3D printed model provided, trialling the supplied Rapid-O2 insufflation device and seeking out higher-fidelity options to cement their learning further. As a result of the initial technical check, most participants were readily prepared to manipulate their webcams and provide satisfactory views to assess their techniques.

The sessions ran reasonably to time, but facilitators noted the Zoom meeting time reminders were often too subtle to note, and a second personal timer was invaluable to keep to time. One breakout room facilitator, who felt their first session overran, contacted participants for a follow-up Zoom session to cover any techniques that felt rushed. Interestingly, another facilitator noted they missed the camaraderie of working with other faculty members and found the facilitator debriefs between sessions important.

Survey responses

Discussion

This report describes the presentation of a fully virtual workshop for an emergency response activity. Although there is some confusion in terminology, we believe this is the first time a workshop such as this has been attempted with all of the participants and most of the facilitators located remotely, either at home or (for two participants) in a work environment.

Feedback from workshop participants was generally positive, with most respondents saying the workshop had been ‘better than expected’. The 3D printed larynx and airway model components contributed to this positive feedback, along with the physical CICO kit that enables ongoing practice of eFONA technical drills.

The delivery of material from a studio allowed high-quality, high-resolution AV production to be streamed to participants. This ensured the physical skills presented in the workshop were easily explained and demonstrated. While it would be possible to undertake this without a studio, the studio and technical staff ensured that facilitators were much more able to concentrate on the delivery of material without concerns about managing breakout rooms or technical difficulties, or guaranteeing high-quality images and audio were being streamed and received.

Adequate preparation of AV, information technology and technical components was vital to delivering what the participants perceived to be a technically flawless session with no audio or video issues. Poor or inconsistent audio quality has been found to be a drawback of other online medical education events, and we strongly recommend engaging AV technicians and rehearsal to avoid this.^8,9 The technical rehearsal the day prior was invaluable to facilitators, with advanced opportunity to communicate with the technical team. The rehearsal allowed improvements to be made to camera angles, lighting, positioning and fixation of the models on the demonstration table, while breakout room facilitators setups could also be checked.

Despite instructions, few registrants attended the online technical check scheduled a week prior to the workshop. In future, we would change the information regarding start time to ensure enough time was left for participants to do a technical check.

When organising an international online conference, Reshef et al. noted challenges ‘related to different emotional engagement due to the lack of in-person interaction’. ⁸ Our experience mirrors this. Lack of social interaction associated with virtual conference attendance was considered to be both an advantage and a drawback, depending on the participant, which may suggest individuals’ differing learning styles and personality types. Other adjustments need to be made, as the immediacy of feedback from participants to presenters can be lost in a virtual setting (e.g. eye contact, clapping), but we feel adequate preparation, facilitator effort and the small breakout groups allowed participants to engage more fully in these CICO workshops.

One respondent suggested that participants who had personal experience with CICO events (and were happy to discuss these) could submit scenarios prior to the workshop to be included in the clinical scenario section. Workshop participants are always asked about previous CICO personal experience as part of the central session, and this is coordinated into the workshop ‘on the fly’, but a more formalised approach could benefit future workshops.

COVID-19 has had an enormous impact on the healthcare system, changing the fabric of our workplace and patient care, whilst also disrupting continuing medical education (with examinations, conferences, research and clinically based teaching postponed, cancelled or materially altered^4,10,11). Whilst delivery of lectures has pivoted relatively easily via online platforms, ¹² more needs to be done to facilitate technical skills training ¹³ and the collaborative interaction that may be lost without face-to-face learning.^2,11 Completely halting these components of continuing medical education is untenable. As a profession, we need to be enthusiastic and innovative with our solutions to this problem. In a time of social distancing, our airway group has been heartened by the collegiality and collaboration experienced during the planning and execution of these virtual CICO workshops. Social media has made it easier to reach out to international colleagues and share experiences,^14,15 allowing access to open-source materials to enable 3D printing of airway models.

We are mindful of what cannot be delivered in a virtual workshop. There was a limitation to what equipment could be sent to participants, and no-one had access to an oxygen supply at home, but participants were encouraged to use this workshop as a springboard to investigate equipment used at their own health networks. Whilst we had extensive technical backup and good internet connections, we appreciate this might not be the case globally.

Future adaptations of this concept would, of course, involve other technical skills. While the clinical task may be different from the task that is practised at a home workshop, there is evidence that if the components are the same, then skills will be improved. Notably, in surgery, Kneebone et al. ¹⁶ used artists and craftsmen such as lacemakers to teach novice surgeons skills such as suturing techniques. While we might not need to go to these extremes, it is clear that analogous practice will result in enhanced confidence and technical ability.

The ability to deliver technical skills workshops remotely also gives rise to opportunities to teach these skills to health professionals in low- and middle-income countries. High-quality videos of the demonstrations can be provided, along with the equipment mailed to their workplace. The only prerequisite would be an adequate internet connection, which may be a hurdle in countries with inadequate infrastructure. ³

In summary, we successfully delivered a virtual technical skills training workshop that met stringent quality standards for CPD. This technique also demonstrates previously unperceived advantages to virtual learning over face-to-face conference attendance, such as improved equity of access.^3,17

Supplemental Material

Supplemental Material

Supplemental Material