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By Jason Gilliam, NEMSQA
For 25 years, I’ve dedicated my career in EMS to enhancing patient care, often grappling with what seems like a fundamental challenge: why is something so basic so difficult to master consistently?
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My journey began with early specialty courses, like Jim Rich’s SLAM class, focused on improving airway management. Since then, I’ve taught techniques, coached and counseled, yet the truth remains: airway management is basic, but it’s far from easy.
While I’ve witnessed dramatic improvements in individuals and small teams, these successes have rarely been reliable or scalable. Most EMS agencies tracking their performance struggle with consistency in airway management. Why does this persistent challenge exist, and what can we do to deliver more reliable care to our patients?
Over the past 18 months, I’ve had the privilege of working with the National EMS Quality Alliance’s (NEMSQA) Airway Collaborative, helping to implement successful change ideas across 61 agencies in North America. One standout is the St. Charles County Ambulance District (SCCAD), which has consistently achieved high performance in two key NEMSQA measures:
- Adult Respiratory-02 (Oxygen Administration for Hypoxia), and
- Adult Airway-18 (Capnography Use with Advanced Airway)
To understand their remarkable results, I spoke with Chad Metz, a clinical leader at SCCAD. What I learned is that their success isn’t due to a single intervention. Instead, it’s the product of a well-integrated culture, supported by:
- Intelligent design
- Real-time feedback
- Intentional data workflows
Their approach offers valuable lessons for other systems striving to improve.
Culture first: “Capnography goes on everyone”
At SCCAD, the use of waveform capnography during airway management isn’t just a best practice; it’s the undisputed norm. They’ve proactively removed any mental barriers for paramedics by never debating the increased cost of capnography cannulas versus standard nasal cannulas. As Metz puts it, “We’ve never been afraid to put capnography on people. It’s always been expected.” This expectation is deeply ingrained, starting with the 3-week onboarding for new paramedics, which includes scenario-based reinforcement.
This widespread standardization is crucial to SCCAD’s success with Airway-18, and it’s further strengthened by rapid, personalized feedback. Metz credits former Division Chief Stephanie Ashford with fostering a culture where feedback was never delayed or watered down. “She would call providers directly — not just email or send a QI message. A quick phone call saying, ‘Hey, I saw you intubated. Where’s the capnography?’ That made a difference.”
Engineering reliability through ePCR design
SCCAD has custom-engineered the ImageTrend ePCR platform to guide and reinforce provider documentation, moving far beyond an out-of-the-box solution. This thoughtful design directly contributes to their reliable performance.
They’ve implemented several key features:
- Power Tools automate documentation by auto-populating related medications and procedures. For example, selecting a non-rebreather automatically selects oxygen, eliminating extra clicks and ensuring accurate documentation for the NEMSQA Respiratory-02 measure.
- Situation Tools provide protocol-based bundles, grouping airway interventions, assessments and medications for easy selection. This streamlines the documentation process and promotes adherence to best practices.
- Internal Messaging allows QA reviewers to directly notify crews about charts needing attention. Providers can then edit records, with comprehensive audit trails tracking all changes. This means performance queries always reflect the most current and accurate data.
- Custom Timers enable precise timestamping of interventions, significantly improving the accuracy of both airway and cardiac arrest metrics.
As Metz summarizes, “These tools reduce friction. We’ve made it so that oxygen and capnography are both easy and expected. And we track it.”
| More: NEMSQA 2024: Dr. Jeff Jarvis on airway safety and the path to EMS improvement
Visualization and verification
SCCAD has long leveraged the power of capnography trend lines and waveform displays available through their monitor’s back-end viewer. While they are transitioning to new monitor technology, potentially making the continuation of this methodology more challenging, the value of these visualizations remains clear.
These visual tools are crucial for “double-checking documentation and verifying performance, especially when reviewing difficult airway cases,” according to Metz. He explains, “You can see exactly when the patient was intubated based on waveform changes.”
Metz expresses optimism that future device integrations will enable bidirectional data syncing, allowing for patient monitor data to be directly overlaid onto PCR timelines, further enhancing their ability to visualize and verify patient care.
Airway pit crews and continuous spread
SCCAD is now prototyping an airway management pit crew model, drawing inspiration from successful implementations in cardiac arrest. As Metz explained, “We did this for CPR — why not airway?” While not yet formalized, the concept is gaining traction. “We’ve tried to include airway content in every little training module,” Metz noted. “It’s word of mouth — hallway conversations, small PDSAs [Plan-Do-Study-Act cycles]. It spreads.”
The pit crew concept emphasizes:
- Pre-oxygenation with blood pressure checks every 2 minutes.
- Clear role assignments, including a dedicated team member focused solely on the monitor.
- Visual job aids are currently being developed by their training team, who have a background in graphic design to support these roles.
Airway management lessons for other agencies
Metz offers several key takeaways for EMS systems aiming to elevate their airway care performance:
- Embed expectations into your culture, not just your training. Make desired practices the norm, not just something taught in a classroom.
- Optimize your ePCR system to eliminate documentation hurdles. Automate processes wherever possible to reduce friction for providers.
- Review performance regularly and personally. A direct phone call often yields better results and understanding than an email for feedback.
- Leverage waveform data for both coaching and verifying performance. Visual data provides invaluable insights for improvement.
- Don’t wait for a perfect solution. Even small, continuous improvements can spread organically throughout your system.
With over 250 unionized paramedics, SCCAD demonstrates that scale doesn’t hinder high performance; it simply emphasizes the critical importance of consistency. By blending strong clinical values with intelligent data practices, they’ve made capnography and oxygen documentation more automatic and reliable.
ABOUT THE AUTHOR
Jason Gilliam is project manager, National EMS Quality Alliance.
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