VA Collaboration Sparks Innovation: Out-of-OR Airway Management Training Champions Veteran Safety

A simulated crisis is underway: a morbidly obese patient with severe pneumonia is decompensating rapidly. This isn't an actual emergency room crisis; it’s a controlled, psychologically safe training environment where clinical teams master critical skills before they face them at a Veteran's bedside.

This week, a dynamic joint effort between the VA Fayetteville Coastal Health Care System (FVAMC) and the Salisbury VA (SBYVAMC) brought specialized clinical teams together for the newly evolved SimLEARN Out-of-OR Airway Management (OOOAM) 2.0 curriculum. The national program trains non-anesthesiology frontline clinicians including emergency and intensive care physician associates (PAs), APRNs, hospitalists and respiratory therapists (RTs) to confidently manage difficult airways during off-hours, weekends, and nights when anesthesia staff are not in-house.

A Decade of SimLEARN Innovation

Originally debuted by SimLEARN staff as a program in January 2013 in Orlando, Florida, the course broke traditional medical education paradigms by introducing mandatory simulator practice and critical decision-making assessments over classroom slides. The clinical curriculum had a massive overhaul in 2019 and added video based flipped-classroom modules.  Today, 70 VA facilities nationwide actively run this national course, bringing proven, evidence-based literature directly to the bedside.

The regional training session was led by Dr. Jessica Feinleib, MD, PhD, FASA, CHSE, an anesthesiologist from the West Haven VA and Acting Medical Director for the National VHA Simulation Center (SimLEARN).

"This course is entirely about optimizing patient safety and bringing the absolute best, evidence-based techniques directly to the bedside," said Dr. Feinleib. "We are deeply embedded in High Reliability Organization (HRO) principles. In the VA, we are actively looking at what the literature proves works and executing it immediately to give our Veterans the absolute vanguard of care."

The program is anchored by regional champions, including local simulation technician Jerome Perry and Ivelca Nintzel, CRNA, a local FVAMC OOORAM Instructor and coordinator, alongside Gina Reid, the SBYVAMC Simulation Coordinator.

"Mr. Perry and I have been laying the groundwork for this project since March, and seeing it come to such successful fruition is incredibly rewarding," added Ivelca Nintzel. "Ultimately, it comes right back to our core HRO mission: it is all about the Veteran. When we standardize and build these multidisciplinary skills, our Veterans win every single time through improved safety and better clinical outcomes."

Sustainable Training Aligned with VHA Directive 1157

The core focus of this session was an intensive "Train-the-Trainer" model to build regional autonomy. Anesthesiologists, CRNAs, Emergency Physicians and Intensivist physicians are all eligible to become local trainers to support sustainment of this ongoing training.  During this session intensivists and emergency physicians from Fayetteville and CRNAs from Salisbury VA were trained to teach the OOORAM 2.0 program.  

This competency framework is precisely tailored to align with the distinct skill sets defined under VHA Directive 1157 (Non-Operating Room Airway Management), training local frontline learners like PAs Daniel Lane and David Crenshaw, alongside Respiratory Techs Kelley Willis (RRT-1) and Ian Luca (RRT-2) across three distinct levels of airway management expertise to ensure standardized care on all shifts.

Breakthrough Simulation and Future Horizons

Driven by the evidence-based protocols of the 2.0 curriculum, the high-stress simulations pushed providers to utilize innovative techniques over antiquated ones:

• Peri-Airway Nasal Oxygenation & Nasal CPAP: Moving away from standard 100% non-rebreather masks, which lack the required pressure to stent open failing airways.
• "Plastic Agnosticism": Prioritizing overall patient oxygenation over a fixation on a single modality, training providers to rapidly pivot to a supraglottic airway device (SGA) to expedite an invasive airway during a code, or as a back up to a traditional breathing tube.
• Continuous Waveform ETCO2: Always deploying quantitative end-tidal carbon dioxide monitoring to instantly confirm correct ventilation.
• The Power of Gravity: Simply elevating the head of the bed for non-coding patients to instantly optimize clinical views and improve oxygen saturation.

Supported by Dr. Dora Franzoni, Director of Out-of-Operating-Room Airway Management and Dr. Jason Guevara, Chief of Surgery, this cross-professional collaboration ensures VHA teams build seamless teamwork long before an emergency occurs.

The success of this curriculum paves the way for the incoming Emergency Ambulance Service (EAS) variant of the course. New EAS director Dr. Anthony Vogt joined the cohort as an instructor candidate to prepare for this national rollout. Directed at VA EMTs and paramedics, the EAS program introduces field skills like cricothyrotomy and specialized airway decontamination, standardizing emergency medical direction across all VA ambulance services.

The Ultimate Winner: The Veteran

At its core, the collaboration between SimLEARN, Fayetteville, and Salisbury highlights the best of the VHA’s mission. By bringing emergency medicine, anesthesia, critical care, and respiratory therapy together over a simulator rather than a crashing patient, the VA is driving systemic change management and shared learning across different professions.

"It’s much better to meet here and iron out a standardized clinical approach rather than meeting over the bedside of a patient who is in dire straits," Dr. Feinleib concluded. "Every single time we master these skills in the lab, a Veteran wins a safer, better outcome at the bedside."