719 - Attention of LEadeRs during Tracheal intubation (ALERT); An eye-tracking study

Publication Number: 1696.719

Heidi M. Herrick, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Charis Lim, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Shreyas Singh, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Elizabeth Foglia, Children's Hospital of Philadelphia, Swarthmore, PA, United States

Background: Neonatal tracheal intubation (TI) is a critical, high-risk procedure. During TIs, the leader must ensure patient safety and procedural success, which often involves teaching inexperienced airway providers. As staffing allows, this leader should be distinct from the airway provider and remain hands-off. This requires simultaneous awareness of infant vital signs, the length of TI attempt, and provider's intubation technique. A critical aspect of situational awareness is appropriate allocation of visual attention (VA) among multiple different areas of interest (AOI).

Objective: To characterize hands-off leader's VA during neonatal TI and explore how this varies by device, traditional laryngoscope (TL) vs video laryngoscope (VL).

Design/Methods: Single center prospective observational study in at a level III academic delivery hospital examining VA of hands-off leaders during neonatal TI using Tobii Pro eye-tracking glasses. VA was assessed from eye-tracking recordings to pre-specified AOIs including infant, airway provider, VL screen, and vitals monitor to determine gaze percentage, visit count per 10 seconds, and average visit duration on each AOI. Descriptive statistics summarized eye-tracking statistics, patient and provider characteristics, and TI outcomes. Univariable analysis explored differences in VA between TL and VL.

Results: A total of 13 TI attempts across 9 patients were analyzed, including 5 TL attempts and 8 VL attempts. Tables 1 and 2 show patient and intubation attempt characteristics respectively. Leaders' VA differed significantly between device (Table 3). With VL, leaders primarily looked at the VL screen (63.6%) and spent significantly less of their total gaze percentage on the infant (11.7% vs 60%), airway equipment (3.5% vs 23%), and the vitals monitor (2.5% vs 13.6%) than with TL. VL was also associated with lower frequency of visits to the vitals monitor and airway equipment and shorter visit duration on the vitals monitor (Table 3).

Conclusion(s): Leaders' VA patterns differed significantly with VL versus TL, with leaders spending significantly less VA on the infant and the vitals monitor with VL. These findings highlight the impact of technology on provider VA during neonatal TI and the potential impact on situational awareness.

Table 1: Patient characteristics and indication for intubation by device type
TL= traditional laryngoscope; VL= video laryngoscope; SD= standard deviation
1 Can select more than one diagnosis
2 Can select more than one indication for intubation


Table 2: Intubation attempt characteristics and outcomes by device type
TL= traditional laryngoscope; VL= video laryngoscope; NICU= neonatal intensive care unit; NP= nurse practitioner; PA= physician assistant; IQR= interquartile range
1 Premedication defined as atropine, fentanyl, and vecuronium
2 Duration of attempt defined as time from mask off face until re-establishment of ventilation through correctly placed endotracheal tube or mask ventilation if tube was not placed
3 Severe desaturation defined as ≥20% drop in oxygen saturation from highest prior to attempt to lowest during attempt
4 Bradycardia defined as hear rate <100 beats per minute during attempt if heart rate≥100 prior to attempt
* One delivery room intubation attempt missing vital signs


Table 3. Visual attention of intubation supervisor with traditional laryngoscope (TL) versus video laryngoscope (VL) (TL; n=5, VL; n=8)
TL= traditional laryngoscope; VL= video laryngoscope; IQR= interquartile range
1Total gaze duration %=cumulative time each participant gazed on an area of interest, divided by the recorded attempt duration
2Visit count=number of visits within an area of interest per 10 s.
3Visit duration=mean time spent in an area of interest on a single visit.
4Airway equipment=laryngoscope, T-piece, endotracheal tube, stylet, suction device
5Other physical objects=any physical object that was not prespecified as an area of interest