The facilitation of advanced airway management in the prehospital setting is a critical technique for patient care. Historically, the modalities and techniques have changed in prehospital transport. Included in these updates is the advancement of intubation devices and enhanced cognitive offload tools.

Preparation

To start, one area that tends to be forgotten is one’s basic preparation before performing intubation. Utilizing basic airway techniques to prepare the patient to their fullest potential before attempting the intubation can facilitate first attempt success, which obviously is the best attempt. From a research perspective, we found there was almost a seven-fold increase in opportunity for a physiological adverse event when we perform intubation in the air medical transport setting. More specifically, these adverse aspects were related to hypoxemia, hypertension, and cardiac arrest.

To improve on this, implementation of the ‘thenar eminence’, or TE technique, was implemented. Picture 1 shows an improvement in ventilation versus the traditional E-C clamp grip. In addition, implementing the difficult airway pneumonic – the HEAVEN criteria (see Table 1) – facilitates the task. HEAVEN allows not only for the prediction of a difficult airway, but also provides a delineation between when to choose a direct view or a video view with a standard geometric videoscopic intubation device.

Intubation locations

In years past, there has been discussion on the ‘load and go’ with patient care on a scene call. The rationale for this procedure considered the busy scene with a helicopter tying up providers that could be assisting with other scene issues. Therefore, the onset of in-helicopter intubations versus on-ground intubations came into existence. This led to a concern about first-pass success and adverse events occurring when intubating in the air or on a moving vehicle versus a stationary environment. Prior to the evaluation of this study, the percentages of first-pass success varied from the 50 percentiles to up to the 80 percentiles, and there was limited data on the location in which they were performing the intubation. Initial evaluation also showed an almost equal first-pass success rate on the ground or in the air. However, there was an approximately 10-per-cent increase in desaturations when the patient was intubated in a moving setting. This was discussed and consideration of preparation of the patient was noted to be one of the largest influencing factors. When on the ground in a stationary position, there are more hands to help, better opportunities to utilize practitioners around to help prepare for the intubation, and additional help with the use of a standardized rapid sequence intubation checklist.

RSI checklist

Introduction of an intubation checklist or airway dump kit has been used for many years in the helicopter emergency medical service (HEMS) setting. This allows for a standardized approach to airway management and a decrease in the possibility of missing a key step. Checklists have been implemented in multiple parts of complex tasks to prevent task saturation. It is believed that the advancement of the idea of a checklist was implemented around 1935 after a Boeing aircraft, Model 299, crashed shortly after take-off. “Instructions should be concise, but enough information must be provided so that actions are performed correctly, and essential issues are considered.” (Burian, B. K. 2006). Following this design, a checklist was made for prehospital providers that took into consideration human factors improved through the utilization of a checklist (Table 1). “Acutely stressful situations can cause heightened arousal, which by extension can impair vital cognitive functions such as situational awareness, decision making, problem-solving, and memory recall.” (Lauria, M. et al., 2017). This checklist was designed to facilitate the intubation challenge and response. It also permitted a separate party from the flight crew to read the steps to prevent selection bias and the skipping of important components. “The US National Transportation Safety Board (NTSB) has found that in 84 per cent of 37 accidents attributed to crew error between 1978 and 1990, first officers had failed to challenge errors or unwise decisions made by captains.” (Bienefeld, N., Grote, G., 2012). Preliminary evaluations of prehospital RSI checklists have helped improve the opportunity for first-pass success and prevention of missed steps during the process.

Quality

Implementing a quality dashboard or metric to evaluate internal airway management is seminal to determining areas of improvement or areas of success. However, designing a dashboard is only limited to the data you collect. Therefore, we devised a study related to continuous quality improvement (CQI). This study utilized a data collection / performance improvement tool that collects more than 150 data elements per intubation. “The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success.” (Olvera, D. et al., 2018). Utilizing the data internally can help breakdown specific issues related to the selected program; however, this could limit the extent of where the program stands in relation to the industry.

Hence, the Commission on Accreditation of Medical Transport Systems (CAMTS) has recommended the use of a source called Ground and Air Quality Metrics Transport (GAMUT) database for programs to upload their data in a database that allows for all the data to be blinded out and have the ability to compare a program to the industry. It is the program’s decision to determine how much they want to submit, CAMTS recommends no less than five metrics of data.

The chosen metrics may be those that are performing below the GAMUT ABC (Achievable Benchmarks of Care) scores and/or GAMUT averages; those deemed critical to the program’s performance; and/or those relevant to adverse events. Programs are encouraged to report their metric results to the GAMUT database. (CAMTS, 2018).

This database provides industry benchmarks as well as individual program data.

Conclusion

The goal of ongoing research and investigation highlights the importance of improving first pass success rates through basic instruction. Included in these instructional practices should be knowledge of diverse intubation devices along with appropriate use of checklist utilization. These practices will improve first pass success. To further determine needs and successes, individual programs can be combined into the larger GAMUT to compare and contrast data. Simplistic in form yet powerful in output, successful first-pass intubation practices save lives.