Moderate Sedation Training Program. Airway Management Supervised Experience.

Skills Checklist

MD /ARNP /PA (circle one) Attending / Fellow/ Senior Resident (circle one)
Name: ____________________________________________
Skill S U NP Comments
S = Satisfactory
U = Unsatisfactory
NP = Not Performed
1. Assess baseline vitals, LOC, O2 saturation, pain level.
2. Assess airway- look externally (beard, obesity short
neck, edentulous), Mallampati,
Upper Lip Bite Test, mouth opening,
Thyromental distance
3. Monitor HR, O2 saturation and ETCO2 continuously;
visually monitor LOC & level of responsiveness.
4. Perform airway management maneuvers:
• Head-tilt chin lift
• Jaw-thrust
• Chin-lift
5. Reassess airway patency after any maneuver.
6. Maintain cervical alignment in patients with known or
suspected cervical spine injury.
7. Demonstrate correct sizing and insertion of oral
airway
8. Ventilate patient adequately using the bag-valve
mask without evidence of stomach insufflation.( 1 & 2
handed technique)
9. Assess ventilation adequacy: visual chest rise, pulse
oximetry
10. Report significant patient reactions during and after
procedure.

Evaluator (Attending or CRNA) Name (print): ________________________

Evaluator (Attending or CRNA) Signature: __________________________ Date: ______________________
Overall Result: Satisfactory/ Unsatisfactory (circle one)
Submit: Email checklist (scan/photo) to modsed@uw.edu

Updated February 2020 Page 1 of 4

 Moderate Sedation Training Program. Airway Management Supervised Experience.
Skills Checklist
MD/ARNP/PA (circle one) Attending/Fellow/Senior Resident (circle one)
Name: ___________________________________________
Skill S U NP Comments
S = Satisfactory
U = Unsatisfactory
NP = Not Performed
1. Assess baseline vitals, LOC, O2 saturation, pain level.
2. Assess airway- look externally (beard, obesity short
neck, edentulous), Mallampati,
Upper Lip Bite Test, mouth opening,
Thyromental distance
3. Monitor HR, O2 saturation and ETCO2 continuously;
visually monitor LOC & level of responsiveness.
5. Perform airway management maneuvers:
• Head-tilt chin lift
• Jaw-thrust
• Chin-lift
5. Reassess airway patency after any maneuver.
6. Maintain cervical alignment in patients with known or
suspected cervical spine injury.
7. Demonstrate correct sizing and insertion of oral
airway.
8. Ventilate patient adequately using the bag-valve mask
without evidence of stomach insufflation.( 1 & 2 handed
technique)
9. Assess ventilation adequacy: visual chest rise, pulse
oximetry
10. Report significant patient reactions during and after
procedure.

Evaluator (Attending or CRNA) Name (print): _______________________

Evaluator (Attending or CRNA) Signature: __________________________ Date: ______________________
Overall Result: Satisfactory/ Unsatisfactory (circle one)
Submit: Email (scan/photo) to modsed@uw.edu

Updated February 2020 Page 2 of 4

 Moderate Sedation Training Program. Airway Management Supervised Experience.
Important Instructions
Location options:

During this session, you will be assessed performing basic airway skills, including bag/mask ventilation, on two (2)
patients. This can be done one of the following places:

1. Procedural unit
- If you work in a procedural unit where anesthesia providers cover cases, you may be evaluated by
these providers during the course of a normal day.
- Please let the CRNA or Anesthesia Attending know at the beginning of the day that you are to be
evaluated on your two (2) cases. If they have any concerns regarding the suitability of a certain
patient, they will arrange an alternative patient.
2. In the OR (HMC or UWMC – Montlake or UWMC - Northwest)
You will be assigned to a specific anesthesia attending who will check you off during the induction
phase of two (2) “first-Start” cases at the beginning of the day.
3. In the PACU at HMC
You may be assigned to patients having ECT in the PACU at Harborview instead of patients in the OR.

Instructions applicable to all locations:

- Make sure to print two (2) copies of the Skills Checklist to take to your hands-on airway session.
- Read it ahead of time so you know what to expect.
- Upon successful completion, send your 2 (two) signed checklists to modsed@uw.edu.

Location-specific instructions:

UWMC - Montlake Campus

Contact modsed@uw.edu.
On the scheduled day, go to the OR by 7:00 am in scrubs (8:00am on Weds), with your two (2) checklists, and make
contact with the Anesthesiologist in Charge (AIC) on 89607. They will assign you to a specific Anesthesia Attending in
either the Main OR or Pavilion OR and give you the Attending’s spectralink number for you to call. You will be evaluated
during the induction phase of two (2) “first start” cases.

UWMC – Northwest Campus

Contact Alex Pang: pangask@uw.edu
Dr. Pang will schedule you for a convenient day (Tuesdays & Thursdays are best). On the scheduled day, go to the OR
front desk, located on the second floor in the B/C wing. If coming from outside it is best to park in the F Lot and enter
via the North Entrance. There are double doors outside the operating room that require a badge to enter but you can
pick up the telephone outside the double doors to enter the surgical area. The OR front desk is located next to the white
board inside the secured area. Contact the Anesthesiologist-in-Charge (AIC) on 206 668 4821. They will assign you to a
specific Anesthesia Attending, who is working with 2 CRNAs, and give you the Attending’s number for you to call. You
will be evaluated during the induction phase of two (2) “first start” cases.

Updated February 2020 Page 3 of 4

 Moderate Sedation Training Program. Airway Management Supervised Experience.
Important Instructions

HMC
Contact Raquel Hivera in the 6th Floor Anesthesia Office (6EC-21) mariarh@uw.edu
Tel: 206.744.4371
They will schedule you for a convenient day (Monday, Tuesday, Thursday or Friday only) and give you the code for the
locker room so that you can change into scrubs on the day. On the day, go to the OR by 7:00 am in scrubs, with your
two (2) checklists, and check in with the front desk (48800), asking for the Anesthesiologist in Charge (AIC).

The AIC will assign you to a specific anesthesia attending in either the Main OR or Maleng OR, and give you that
attending’s number to call. You will be evaluated during the induction phase of two (2) first start cases or two (2) ECT
cases – depending on your original scheduling. If you get allocated to the ECT patients there may be a 30 minute delay.
This is rather difficult to predict, as allocation to suitable patients can only happen on that particular day.

VAMC
Contact Stephen Clark in the 3rd floor OR office (3D 104 – Bldg. 100)
Stephen.clark3@va.gov
Tel: 206.716.5958
They will schedule you for a convenient day (likely M, W, or F). He will arrange for you to have access to the locker room
so that you can change into scrubs that day. You should plan to park in the Visitors’ lot and enter the VA through the
main entrance near the Emergency Department. This is building 100. You will then go to the 3rd floor and find the OR.
On the day, go to the OR by 7:00 am in scrubs, with your two (2) checklists, and make contact with the
Anesthesiologist in Charge (AIC). Ask the nursing staff at the front desk who that is for the day. The
Anesthesiologist in Charge will then assign you to a specific Anesthesia Attending and tell you how to get a hold of
them. Your airway skills will then be evaluated during the induction phase of two (2) “first start” cases.

SCCA
Charge Nurse
Tel: 206.606.1329
Tuesdays and Thursdays will be available for airway skills assessment at SCCA, and only ONE (1) person will be able to
complete the training per Thursday. Check the procedure suite schedule (206.288.1329 or in ORCA) to be sure a case is
scheduled. Spaces are limited so if you also work at another hospital in the UW system, please book your session there
instead. Be sure to bring two (2) checklists with you.

Updated February 2020 Page 4 of 4