Airway Mismanagement in the Pre-Hospital / EMS Settings

Airway management is one of the most essential elements during interfacility emergency medical transport. One primary goal is to provide adequate client ventilation up to the point of transfer at the receiving hospital. Advanced airway management and intubation is considered a technically complex and high risk procedure particularly with neonatal and medically complex clients. Variations in training, education and procedural exposure and maintenance are some of the factors associated with client outcomes along with access to adequate oxygen supply on route. Accurate and complete documentation of the resuscitation and stabilization is required to help demonstrate the timeliness and adequacy of the emergency interventions.

Expected Outcomes

Adopt a standardized current evidence-based algorithm, checklist, and / or decision tools to guide clinical decision making during transport ventilation and oxygen administration.

Implement strategies to support a work culture of client safety and psychological safety.

Adopt current best practice quality indicators for airway management and intubation in the pre-hospital emergency medical services (EMS) settings.

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• EMS – emergency medical services also known as ambulance services or paramedic services
• ETT – endotracheal tube
• Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning

Common Claims themes and Contributing Factors

Organizational

• Lack of a formal process to escalate time sensitive concerns and disagreements related to airway management and intubation between transport and / or medical escort team members prior to or during transport.
• Perceived and actual tolerance of unprofessional, unsafe, and disruptive behaviours involving members of the transport team and medical escorts.
• Inability to perform critical tasks such as equipment monitoring, client assessments and / or client ventilation or view critical equipment monitors due to:
  • Space constraints in ground vehicle and / or aircrafts due to small interiors and / or configurations; 
  • Use of the sending facility’s equipment and supplies that are not compatible with ground vehicle and / or aircraft interior.

Oxygen Equipment and Supply 

• Portable oxygen supply is exhausted prior to the arrival of the client at the accepting hospital due to:
  • Paramedic / EMS supply of portable O2 to stabilize the client at the sending site prior to transport, leaving insufficient supply for the transport;
  • Transport delays or constraints that lead to the supply of portable O2 being exhausted during transport; 
  • The inability to utilize backup and / or the sending site’s portal oxygen supply during transport due to tank, ventilator and / or regulatory incompatibility.
• Inability to change out oxygen tanks due to back-to-back calls.

Knowledge and Judgement

• Failure to confirm and document placement of ETT prior to departure. 
• Inadequate sedation and / or paralysis orders where indicated.
• Inadequate physical and / or chemical restraints to prevent unintended extubation.
• Delays in advance airway management and / or intubation by the transport team and medical escorts due to lack of:
  • Skills, confidence in skills, and / or loss of situational awareness, particularly with neonatal and pediatric clients;
  • Lack of familiarity with airway management for neonatal and pediatric clients;
  • Lack of familiarity with ground vehicle and / or aircraft equipment, supplies, and configuration.
• Last minute / chaotic preparation of supplies and equipment for neonatal and pediatric transports contributing to: 
  • Missing routine and specialty equipment and supplies (e.g. neonatal endotracheal tube holder, oxygen / air blender);
  • Failure to perform checks prior to departure to the referral site;
  • Inadequately charged portable equipment, including backups.

Communication 

• Multiple EMS / hospital transfers due to a misunderstanding of the client’s clinical needs linked to a failure to obtain an adequate and appropriate medical history and communicate key findings during handovers, particular for neonatal and pediatric clients. 
• Assumptions made by the transport team that the sending facility would be providing or have available the specialized or non-standard equipment and supplies (e.g., iNO, CPAP, bariatric stretchers and blood pressure cuffs) or specialized medical escorts.
• Failure to communicate portable oxygen supply concerns during transport with the most responsible transport physician / practitioner and / or coordinating agency or ambulance dispatch.
• Care disagreements between members of the transport team or between the transport team and medical escorts that delayed transport and interventions surrounding advanced air management and intubation. 
• Failure to communicate non-standard care and transport decisions made by medical escorts and transport team members to the most responsible transport physician / practitioner. 

Documentation

• Incomplete and inconsistent records of airway management, resuscitation, and re-intubation efforts. 

Knowledge and Judgment

• Inadequately ventilated clients, due to:
  • Lack of familiarity with transport ventilators and related supplies including settings especially for neonatal and pediatric clients;
  • Absence of a staff member or medical escort with the appropriate skills, knowledge, and experience in transport ventilation-related equipment and airway management.
• Lack of compliance with local and provincial oxygen equipment standards and guidelines.
• Clinical, medical, and administrative decisions to transport without an adequate supplemental oxygen including decisions made without direction from the referring, consulting, base hospital, and / or transport medicine physician.
• Clinical judgment issues involving medical escorts due to lack of familiarity, training, and experience with the:
  • Transport team’s administrative, clinical, and equipment protocols;
  • Provincial and regional transport guidelines;
  • Transport medicine evidence-based practices;
  • Physical environment and configuration of ground vehicles and aircrafts.
• Lack of clarity in identifying the most responsible practitioner to direct and oversee care decisions prior to and during transport.

Mitigation Strategies

Care Processes

• Adopt best practice for obtaining a comprehensive medical history, in particular for neonatal and pediatric clients (Huynh, Bahr, Harrod, & Guide, 2020) (Patrick, 2021).
• Adopt a standardized current evidence-based algorithm, checklist, and / or decision tools to guide clinical decision making during transport ventilation and oxygen administration that includes (but is not limited to):
  • Difficult / problem airways;
  • Requirements for transporting a client in the absence of adequate and appropriate oxygen supply; 
  • Discussion with overseeing / transport physician or practitioner to address contingencies where needed.
• Implement formal strategies to reduce inadvertent selection of excessive oxygen flow rates during ground vehicle and aircraft transport.
• Implement formal strategies to ensure oxygen supplies and equipment for all fleet and contracted ground vehicles and aircrafts meet or exceed (where allowed) provincial / territorial ambulance equipment standards.

Safety Culture

• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Early response to suspected and actual clinical deterioration, including seeking assistance from peers and other resources (where available);
  • Assertive and respectful questioning and challenging of care decisions (in order to obtain clarity and/or to advance client safety concerns);
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation (CSA Group, 2018).
• Adopt a standardized and formalized chain of command (‘escalation’) protocol for the rapid escalation of unresolved care disagreements related to concerns about questionable client conditions, orders or care delivery (Canadian Medical Protective Association, 2021) (Canadian Patient Safety Institute, 2020). 

Equipment, Supplies and Technology

• Implement formal strategies to ensure access to specialized equipment (e.g., neonates or bariatric clients), not routinely available in ground vehicles or aircrafts, are communicated and negotiated with the sending hospital prior to the transport team arrival.
• Implement formal strategies to reduce the need for last minute / chaotic preparation of supplies and equipment necessary for transports (Alberta Health Services, 2014). 

Medical Escorts

• Adopt a standardized medical escort guideline / protocol that includes (but is not limited to):
  • Roles and responsibilities of the escorts;
  • Processes to ensure compatibility and availability of equipment and supplies with the ground vehicle and / or aircraft; 
  • A list of standardized equipment and supplies available on fleet and third party ground vehicles and / or aircrafts (both rotary and fixed wing);
  • Documentation requirements during transport;
  • Code of conduct for medical escorts and transport team members (ornge, n.d.).
• Implement formal strategies to ensure the medical escort guidelines / protocol are shared with both sending and accepting facilities.

Team Training and Education

• Implement formal strategies to support and enhance the interdisciplinary team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding advanced airway management including (but not limited to):
  • Mechanical ventilator and troubleshooting;
  • How to calculate oxygen requirements for the estimated duration of a transport and unanticipated incidents; 
  • Airway anatomy for neonates and pediatric clients;
  • Selection of laryngoscope blade length;
  • Difficult airways and complex injuries and presentations (e.g., maxillofacial injury and persons with a high body mass index).
• Ensure the team training and education strategies include:
  • Opportunities for interdisciplinary skill drills and simulations (e.g., scenarios such as ‘can’t intubate, can’t oxygenate’, missing ventilation and oxygen equipment and supplies, and portable oxygen supply exhaustion) (Andresen, Kramer-Johansen, & Kristiansen, 2022);
  • Team and practitioner situational awareness (‘helicopter view’) and human factors.
• Encourage paramedic and EMS team members to retain records of their participation in workshops, skill drills, and recertification initiatives related to ventilation and airway management.

Documentation

• Ensure complete and timely and documentation of all advanced airway management and intubation activities, including (but not limited to):
  • Confirmed placement of tracheal tube; 
  • How the tube was secured;
  • Sedation and paralysis orders;
  • Physical and chemical restraints applied;
  • Communication of non-standard care ventilation, oxygenation, and transport decisions made by transport team members or medical escorts to the most responsible transport physician / practitioner.

Monitoring and Measurement

• Adopt a standardized, interdisciplinary, collaborative and evidence-based protocol for conducting quality of care reviews involving airway management and intubation in the pre-hospital EMS setting resulting in client harm or death (Machen, 2023); incorporate system thinking and human factors concepts into the review process.
• Implement formal and targeted strategies to monitor and measure the effectiveness and efficiency of, and adherence to local and provincial / territorial transport medicine, equipment, and supply standards.
• Adopt standardized current best practice quality indicators for the pre-hospital EMS settings (land and air) (Edwards, FitzGerald, Franklin, & Edwards, 2020) (Basnett, 2022) (National EMS Quality Alliance, 2021) (Health Quality Council of Alberta, n.d.) (Ministry of Health Ministry of Long-Term Care, n.d.) (Bigham, et al., n.d.).
• Incorporate learning from local, provincial, and national pre-hospital EMS safety reviews and data into local protocols as well as staff education and training. 

References

• Alberta Health Services. (2014). Vehicle and Equipment Readiness. Retrieved from Alberta Health Services: https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-ems-vehicles-equip-readiness-ps-ems-01-01.pdf
• Andresen, A. L., Kramer-Johansen, J., & Kristiansen, T. (2022). Emergency cricothyroidotomy in difficult airway simulation – a national observational study of Air Ambulance crew performance. BMC Emergency Medicine, 22(64). doi:doi.org/10.1186/s12873-022-00624-6
• Basnett, E. (2022). California EMS System Core Quality Measures Report Calendar Year 2021. Retrieved from https://emsa.ca.gov/wp-content/uploads/sites/71/2022/11/CQM-Report-Final-SYS-100-12-2021-Data_11.29.2022.pdf
• Bigham, B., Morrison, L., Maher, J., Brooks, S., Bull, E., Morrison, M., . . . Shojania, K. (n.d.). Patient Safety in Emergency Medical Services Advancing and Aligning the Culture of Patient Safety in EMS. Retrieved from https://www.patientsafetyinstitute.ca/en/toolsresources/research/commissionedresearch/patientsafetyinems/documents/patient%20safety%20in%20ems%20full%20report.pdf
• Canadian Medical Protective Association. (2021). Resolving conflict between healthcare providers. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2021/resolving-conflict-between-healthcare-providers
• Canadian Patient Safety Institute. (2020). The Safety Competencies: Enhancing Patient Safety Across the Health Professions. 2nd Edition. Edmonton, AL.
• CSA Group. (2018). Z1003.1-18 Psychological health and safety in the paramedica service organization. Toronto ON: CSA Group. Retrieved from https://www.apbc.ca/wp-content/uploads/2022/09/CSA-Z1003.18-Paramedic-Psych.pdf
• Edwards, K., FitzGerald, G., Franklin, R., & Edwards, M. (2020). ir ambulance outcome measures using Institutes of Medicine and Donabedian quality frameworks: protocol for a systematic scoping review. Syst Rev, 9(72). doi:doi.org/10.1186/s13643-020-01316-
• Health Quality Council of Alberta. (n.d.). New Study: EMS Key Performance Indicators. Retrieved from https://hqca.ca/feature-story/new-study-ems-key-performance-indicators/
• Huynh, T., Bahr, N., Harrod, T., & Guide, J. M. (2020). When Seconds Matter: Neonatal Resuscitation in the Prehospital Setting. Pediatrics, 146, 372. doi:doi.org/10.1542/peds.146.1MA4.372a
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• Ministry of Health Ministry of Long-Term Care. (n.d.). Land Ambulance Key Performance Indicators. Retrieved from https://www.health.gov.on.ca/en/pro/programs/emergency_health/land/default.aspx
• National EMS Quality Alliance. (2021). NEMSQA Measures. Retrieved from National EMS Quality Alliance: https://www.nemsqa.org/measures
• ornge. (n.d.). Medical Escorts. Retrieved from ornge: https://www.ornge.ca/healthcare/medical-escorts
• Patrick, C. (2021, November 10). The pediatric general assessment triange. Retrieved from EMS1: https://www.ems1.com/ems-products/neonatal-pediatric/articles/the-pediatric-general-assessment-triangle-KE8VtMVnpbpRIJgh/