#note/rubric | #on/airway | #on/emergencymedicine | #on/emergencymanual | #on/bougie **Granular Rubric for Observing Bougie-Assisted Intubation** **Scale:** • **1 = Needs Improvement** (Incorrect technique, delays, excessive movement) • **2 = Developing Competency** (Mostly correct but with inefficiencies) • **3 = Mastery** (Efficient, minimal movement, precise execution) **Rubric for Bougie-Assisted Intubation** | **Category** | **1 - Needs Improvement** | **2 - Developing Competency** | **3 - Mastery** | **Score (1-3)** | | ----------------------------------------------------- | ----------------------------------------------------------------------- | ------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------- | | **1. Naming the Situation & Setting the Team** | Does not verbalize reasoning or team roles clearly. | Partially names the situation and assigns roles but lacks clarity or structure. | **Clearly states: “We are intubating because… so we need to consider…” Assigns roles: “I’ll get us organized and I need your help. We need meds, monitor observer, airway lead, documentation, etc.” Aims the team: “We have optimized our conditions with patient position and passive oxygenation, we have the equipment we need in the location that works, the next steps are… “** | | | **2. Declaring the Plan & Backup Strategies** | Does not verbalize or delays clear communication. | States plan but does not include backup strategies. | **Clearly describes a structured approach: “Plan A is video laryngoscopy. Plan B is direct laryngoscopy or switching the video blade. Plan C is a supraglottic airway (properly sized iGel) if intubation is unsuccessful. Plan D is surgical airway if supraglottic fails. If oxygen saturation drops below X% and does not recover immediately, we convert to surgical airway.”** | | | **3. Equipment Readiness & Positioning** | Does not organize or retrieve equipment in a timely manner. | Gathers equipment but placement is suboptimal. | **Ensures all required equipment is on the dominant side, within easy reach. Includes video and direct laryngoscope blades, bougie, ETT, 10 mL syringe, suction, BVM with PEEP valve, capnography, and backup airway devices (iGel, scalpel, tube).** | | | **4. Bougie Selection & Preparation** | Uses incorrect bougie shape or fails to prepare it properly. | Selects correct bougie but may require multiple repositionings. | **If using a hyperangulated blade, selects a bougie that can be bent and holds its shape. If using a universal intubating bougie, puts a small bend at the distal end.** | | | **5. Bougie & ETT Handling** | Holds bougie or ETT incorrectly, leading to poor control. | Holds correctly but does not position optimally. | **Loads ETT onto the bougie, holding it between the middle and long fingers at the 23 cm mark (or appropriate advancing depth).** | | | **6. Laryngoscopy & Glottic Exposure** | Poor hand control, excessive lifting, or incorrect blade placement. | Achieves glottic view but with difficulty or extra movements. | **Right hand scissor opens mouth as wide as possible. Holds laryngoscope like wine glass. First looks directly in mouth to watch exposure of uvula. Directs eyes to VL screen. Uses a controlled lift with minimal force, to find and vocalize uvula, then epiglottis, then lifts epiglottis with forward upward pressure in vallecula. Uses right hand on larynx to provide bimanual optimization for maximal glottic exposure, ensuring a clear view of the airway.** | | | **7. Bougie Insertion** | Misaligns bougie, angles incorrectly, or struggles with placement. | Inserts bougie correctly but requires multiple adjustments. | ** Directs eyes to mouth. Inserts bougie parallel to the laryngoscope, with a smooth trajectory toward the glottis. Directs eyes back to screen. Uses a slight rotational motion to guide the coudé tip anteriorly.** | | | **8. Confirming Tracheal Placement** | Fails to confirm tracheal position before advancing the ETT. | Confirms but inefficiently or with unnecessary movement. | **Uses tactile feedback (‘clicks’ of tracheal rings) or ‘hold-up’ at ~40-45 cm as reliable indicators of tracheal placement. Rotates bougie clockwise 180 degrees while passing cords.** | | | **9. Bougie Stabilization** | Unstable hand position, leading to displacement or inefficiencies. | Stabilizes but with excessive movement. | **Optional, if bougie only and tube not loaded, uses left hand to stabilize bougie against the laryngoscope handle while preparing for ETT advancement.** | | | **10. ETT Advancement Over Bougie** | Feeds the ETT too aggressively, causing difficulty passing the glottis. | Advances ETT correctly but with minor resistance or extra movement. | **Assistant introduces ETT over the bougie and hands off control. Operator advances smoothly, rotating 90° counterclockwise if needed to pass the arytenoids.** | | | **11. Bougie Removal & Tube Positioning** | Removes bougie too early or allows tube displacement. | Removes bougie correctly but with some repositioning needed. | **Ensures ETT depth is appropriate before removing bougie. Advances tube only until the cuff is entirely past the cords (22 cm in females, 23 cm in males).** | | | **12. Tube Confirmation & Securing** | Does not confirm placement or secures improperly. | Confirms and secures but with minor inefficiencies. | **Confirms correct placement with capnography, breath sounds, and chest rise. Ensures depth is not too deep, then inflates cuff and secures tube.** | | | **13. Post-Intubation Ventilation & Troubleshooting** | Provides excessive ventilation or fails to troubleshoot complications. | Ventilates appropriately but does not anticipate all complications. | **Uses BVM with PEEP valve, avoids hyperventilation. If patient deteriorates, assesses for pneumothorax or equipment failure.** | | **Total Score: ____ / 42** **Performance Levels** • **40-42 = Mastery**: Minimal movement, optimal efficiency, confident execution. • **36-39 = Competent**: Mostly correct technique but some inefficiencies. • **<36 = Developing:** needs significant coaching and improvements