Stress, simulation and skill retention: addressing gaps in eFONA training models: a reply

Abstract

We thank Bhandari and Hao for their thoughtful and constructive commentary [1] on our article [2]. We feel our adaption is practicable, scalable and potentially transformative. A randomised crossover design would have strengthened our methodology, and we are pleased to share that we are currently designing a multicentre randomised crossover study to address this very limitation and further validate our pilot findings.

We agree wholeheartedly on human factors and the importance of high-fidelity ‘cannot intubate cannot oxygenate’ (CICO) simulation training for the whole multidisciplinary team, but this was outside the scope of our study. Currently, high-fidelity CICO training is not mandated in the UK and is only recommended when available [3]. In contrast, low-fidelity, workplace-delivered ‘tea trolley’ scalpel cricothyrotomy training has gained popularity because it is practical, accessible and enables compliance with national training requirements [3]. We agree that such training may be unfamiliar or impractical elsewhere in the world and that cultural sensitivity in scalpel cricothyrotomy training is required. As with many other simple but effective innovations, this model may find broader appeal, particularly given its portability and minimal disruption to workflow.

Regarding the cost implications, we provided manufacturer details for transparency and to allow others to benchmark or source equivalent alternatives suitable for their own settings.

We believe one of the strengths of our study was its quantitative and qualitative assessments of the stress of participants. We consider the measurement of salivary cortisol to be a widely accepted, non-invasive method of quantitatively measuring stress with precision and accuracy [4]. We took steps to control for confounders such as diurnal variation and pre-test activity. While subjective stress assessments such as the NASA Task Load Index or Surgery Task Load Index are validated and widely used [5], we chose to incorporate rich qualitative data from semi-structured interviews, which we found to provide a more nuanced insight into the lived experiences under stress of participants. Nonetheless, the inclusion of both subjective and objective stress measures is an important consideration for future studies, and we thank the authors for the suggestion.

We acknowledge the limitations of our fixed-sequence design and agree that it may have introduced a learning effect. However, this was not our participants' first exposure to scalpel cricothyrotomy technical skills training, which is delivered biannually to all anaesthetists in our institution. The observed improvement in performance during the second session, despite evidence of both physiological and subjective stress, was not accompanied by a decline in accuracy. This may suggest consolidation of procedural memory that is resilient to stress and can be accessed reliably under pressure without performance breakdown or ‘choking’. While we agree that a longitudinal follow-up study assessing skill retention and real-world transfer would have added value, this was beyond the scope of our pilot study.

Concerning evaluation bias, we did indeed employ video reviews which we scored objectively using a system derived from the scalpel cricothyrotomy film and accompanying tutor guide from the Difficult Airway Society [3]. While we believe this strengthened internal validity, we agree that employing blinded assessors would have further reduced bias, and we plan to incorporate this into our next study.