Deploy the video laryngoscope to the ground EMS system-JEMS

2021-12-15 00:24:25 By : Ms. Lily Zhang

Emergency airway management is a high-risk, low-frequency skill in the severe environment of EMS, and it is also one of the most important procedures performed by providers in the pre-hospital environment. Endotracheal (ET) intubation is still the standard procedure,1 but 15-20 intubations are required to obtain baseline proficiency. 2,3 However, skilled training does not necessarily translate into skilled practice. In a study by Wang et al., it was determined that even after 30 intubations, caregivers were still not proficient in direct laryngoscopy (DL) for prehospital intubation (at least a 90% success rate). 3 Low-level development costs Video laryngoscopy (VL) has improved airway visualization, and VL needs to be evaluated and implemented in emergency medicine.

The overall success rate of ET intubation is usually quite high (90-100%), but the first pass success rate of about 58% in DL is still a worrying statistic. 4 The first-pass intubation success rate is a well-defined and established indicator for EMS service tracking, which eventually becomes a sign of success. A high first-pass success rate is critical, because multiple attempts at intubation in the pre-hospital setting can lead to increased complications, including hypoxia, airway injury, and mortality. The literature shows that with each additional attempt, the patient's adverse events will increase significantly. 5 Therefore, the first attempt success rate is a key patient outcome that must be measured and should be emphasized in airway management education, training, and quality improvement.

Background and discussion Effective airway management requires establishing and maintaining a clear (open) airway and ensuring effective oxygenation and ventilation. Ventilation is the physical act of moving air in and out of the lungs, while oxygenation is the loading of oxygen molecules onto hemoglobin molecules in the bloodstream. 6 Failure to manage the airway is the leading cause of preventable death in the pre-hospital environment. Rescuers must recognize the importance of early detection of airway damage, and must take quick and effective interventions. Clinicians should decide to intubate long before the patient shows obvious signs of crisis. The basic criteria are:

1. Respiratory failure (ventilation or oxygenation); 2. Failure to maintain or protect the airway; and 3. There is a certain condition or treatment that requires forced intubation. 7

The provider must be competent in basic and advanced airway procedures to provide appropriate patient care. Photo courtesy of Kevin Nutt

For patients who cannot protect the airway or need breathing assistance, ET intubation is the gold standard of airway care, but it is not always the most appropriate choice for airway management in a pre-hospital setting. 8 Therefore, the provider must have all forms of airway management capabilities and be able to quickly upgrade from basic airway procedures to advanced airway procedures.

In 2012, Baylor College of Medicine (BCM) EMS Collaborative Research Group (CRG) worked with Montgomery County (Texas) Hospital District (MCHD) and Cypress Creek (Texas) EMS (CCEMS) Received funding from the Southeastern Texas Advisory Committee to purchase and deploy 50 King Vision laryngoscopes-enough to store half of the ambulances and surveillance vehicles in the two EMS services. The goal of the funding is to evaluate the role of VL in prehospital airway management compared to traditional DL through clinical research. A VL deployment process plan was developed, which included advanced airway training (based on teaching and skills), clinical research guidelines, troubleshooting, system certification, result measurement, quality review data elements, and continuous capability training.

Guidelines were formulated during the initial development stage of this study, and there is no scientific evidence that VL is better than DL in a pre-hospital setting. Therefore, unless the patient's clinical course needs to be changed, a standardized adult advanced airway management research program has been developed for medical staff. Half of the fleets of the two institutions are equipped with video laryngoscopes, and the other half is rotated every month. When the vehicle is equipped with a video laryngoscope, an ordinary laryngoscope can be used as a backup device. Then a training model of the VL system is developed, which meets the requirements of the research, but is system-specific to facilitate training and deployment.

Teaching and training video laryngoscope training is slightly different between the two organizations. MCHD regularly holds internal quarterly continuing education training courses to regularly strengthen physical skills, while CCEMS conducts shift skills training to help reduce training and deployment costs. All training courses lasted four hours, focusing on current clinical quality plans, protocol revisions, and training on new procedures and skills verification.

MCHD’s courses are limited to 24 participants, and 10 courses are offered in five days (one morning and one afternoon). Nearly 180 MCHD field staff in military uniforms received training.

Nursing staff practiced on six Levitan Airway mannequins to adapt the direct and channel blades on the video laryngoscope. Photo courtesy of Kevin Nutt

CCEMS rotates units into their training facilities during the supplier’s normal shift, which takes approximately three months to complete. CCEMS also includes nursing staff in the training to ensure consistency during the study; these doctors will eventually receive clinical training during the study. Approximately 160 CCEMS providers have received training.

The teaching direction part of the training program is developed from various materials, including basic and advanced airway anatomy, the use of the percentage of glottis opening (POGO) and the Cormack-Lehane score to evaluate the airway, the training video of the King System, and the use of laryngoscopes in the laboratory . All components are included in the PowerPoint presentation and then provided to all EMT mid-level personnel and caregivers. In addition, the presentation was uploaded to an e-learning platform so that the staff of the two institutions could review it as needed to maintain consistency.

In addition to the induction training program, medical staff have also maximized their skills through hands-on practical courses. Purchased two sets of Levitan Airway Training Series models to supplement various other airway training models, including Laerdal Airway Management Trainer, Laerdal SimMan, Laerdal AT Torso and Laerdal Heartsim 2000 models. Each Levitan mannequin has a unique mold that provides a different visual experience through various epiglottis shapes and throat appearances. The goal is to create a skills laboratory for video laryngoscopes whose information is stable and easy to replicate over time to allow for consistent onboarding and training of new personnel.

Before employees participate in the quarterly training, alpha and beta tests with clinical staff have been completed to test and review the process time and process. When the participants did not participate in the skill rotation, they took turns to pass the clinical manager's presentation on updating the treatment guidelines and participated in the general question and answer session.

Positioning and troubleshooting After formal teaching and training, each medical staff has 30 minutes to become familiar with King Vision's channels and standard blades, rigid stylets and suction devices. The staff is divided into groups led by four faculty members. Each team member practiced using the blade while the instructor strengthened the troubleshooting skills. Then each military doctor is required to complete six individual skills, including:

1. Disconnect/connect the camera blade; 2. Assess the impact of the post-cartilage; 3. Use C to intubate the mannequin; 4. Use a rigid tube to intubate the mannequin; 5. Intubate the obese chest; and 6. Suction the airway.

Before entering the next stage of training, each nursing staff has undergone a review, verification and verification of each skill. Participants can practice as much as possible at this stage and provide a page of handouts, including teaching points and "pearls"? ? About VL. Once all participants have completed this stage, everyone will be paired with an instructor, and then the skills training will continue.

Skills training and medical certification MCHD and CCEMS believe that VL is a different skill from DL in terms of acquired knowledge, perception ability, proficient movement and adaptation. In 1956, Benjamin S. Bloom, MD, described the concept of Bloom's learning taxonomy, which included the areas of cognition (knowledge), emotion (attitude), and psychomotor (physical skills).

At present, whether it is a variety of psychomotor fields or learning theorists, there are three basic levels in the entire teaching process: imitation, practice and habit. Therefore, on-site training will be conducted every week throughout the study period so that nursing staff can learn and capture these new psychomotor behaviors to ensure the success and efficiency of VL and DL skills. MCHD and CCEMS strive to be consistent with this theme throughout the learning period to ensure that the performance of skills becomes second nature to confident proficiency.

In 2012, the Montgomery County Hospital District and Cypress Creek EMS received a grant to evaluate the role of video laryngoscopy in prehospital airway management through clinical research. Photo courtesy of Kevin Trainer

The skill training process includes Levitan Airway Training Model, Laerdal AT Torso Model and Laerdal Airway Management Trainer. Participants used slot blades and standard blades to intubate each mannequin for a total of at least 16 intubations. This provides a detailed data skill record sheet. In order to reduce the prejudice and the possibility that participants feel that intubation is becoming easier or more difficult, the order of practicing intubation on the Levitan mannequin is random, so each participant gets it through these six models A unique rounding. Each student completed the entire rotation process in approximately 45 minutes, including terminal tests with grooves and standard blades.

1. POGO is for participants and lecturers; 2. Cormack-Lehane scores of students and teachers; 3. Intubation attempt time, from the blade passing the lip to the intubation ventilation; 4. Students' visual analog score for intubation difficulty.

Each doctor also performed an ET intubation skill test on a Laerdal AT Kelly Torso mannequin with a C-neck. The National Emergency Medical Technician Registered Advanced Level Psychomotor Examination Skill Form (Ventilation Management-Adult) has been modified for the VL verification sign.

Although current EMS practice does not require the personal skills certification of caregivers, MCHD is in the early stages of implementing hospital-based certification. Certification is the process of verifying the education, training, and skills of practitioners who provide patient care services within or for a healthcare entity (collecting, verifying, and evaluating information). Some monitoring methods and areas include periodic chart review, direct observation, clinical knowledge, interpersonal and communication skills, and professionalism. 9 Therefore, every doctor must accept a signature at all stages of VL training in order to obtain an official certified medical director of EMS.

Quality improvement and data management Appropriate collection and analysis of patient care data is essential for any EMS system, especially when analyzing critical procedures or new treatment options. In this case, the principal investigator meets with a group of emergency physicians/directors, airway researchers, and field investigators to discuss the study data elements and create a data dictionary/definition for use in out-of-hospital airway reports. These necessary steps meet the primary and secondary outcome indicators and are required for final research data analysis. Data management for quality improvement or clinical research includes defining data tables, developing data entry systems, and querying data for monitoring and analysis. 10

To ensure consistency in reporting across systems, 2 MCHD and CCEMS use the position statement of the National Association of EMS Physicians. All EMS data is captured, stored and extracted from ZOLL RescueNet electronic patient care records.

Research results In the first 100 days of the study, in terms of the success of the first attempt, video laryngoscopes using channel blades are at least as effective as DL [VL 60/84 (71%) and DL 48/71 (68%)]. 11 This The comparison confirms that our training and certification process is adequate.

It is also important to understand that the average use time of DL in this group is 9 years and that most of the use of VL is the first or second time doctors use it on living patients. 12 The four-month run-in period shows that the success rate of the first path using VL channel blades is 90% compared with DL [VL 137/186 (74%) and DL 132/203 (65%)]. Considering the long learning curve of DL, this is crucial. In addition, providers should consider prehospital intubation positions in airway management strategies, as we have found that by moving the patient from the floor to a stretcher, the success rate during DL can be increased. (See Figure 1 below.)

Figure 1: First intubation attempt success rate by patient position

The positive trend of VL benefits continues after this initial phase, and a one-year, multi-agency prospective analysis will be presented at the American Academy of Emergency Physicians Scientific Conference in October.

After the revision of the clinical guidelines analyzed the data and results of the past year, it was concluded that VL is better than DL for our EMS system. Therefore, unless the patient’s clinical course needs to be changed, a revised or post-study standardized adult advanced airway management protocol has been developed for medical staff. Video laryngoscopes are now installed as the main equipment on all vehicles of the two institutions, with DL as a backup.

The new agreement stipulates that both the first and second intubation attempts should be performed with video laryngoscopes. If a third attempt is required, the doctor can choose to switch to a direct laryngoscopy, a supraglottic airway kit, a BLS airway device, or perform surgical airway techniques. All caregivers must record the reasons for their choice. If 3 VL attempts have been reached and the provider is unsuccessful, a backup airway device should be used.

Conclusion The research guided and guided by EMS physicians is the backbone and strength of the scientific development of new training skills, new results-based protocols, and new contributions to the current EMS knowledge system. The VL with King Vision channel blades has proven to be safe and effective, even during periods when experience is limited to one or two human use. The average DL experience of our group is 9 years, but the success rate is still unacceptable. Now is the time to consider transitioning from a skill that is difficult to acquire and maintain to a skill that appears to have a faster learning curve and may result in fewer attempts at intubation and related complications.

More information about airway management from

1. Tintinalli JE, Editor: Emergency Medicine: Comprehensive Study Guide, Fourth Edition. McGraw-Hill: New York, New York, 39-50, 1996. 2. Wang HE, Domeier RM, Kupas DF, etc. Recommended Guidelines for Unified Reporting of Out-of-Hospital Airway Management Data: Position Statement of the National Association of EMS Physicians. Pre-hospital emergency care. 2014;8(1):58—72. 3. Wang HE, Seitz SR, Hostler, etc. Define the learning curve of nursing students for tracheal intubation. Pre-hospital emergency care. 2005;9(2):156—162. 4. Stewart RD, Prime Minister of Paris, Prime Minister of Winter, etc. On-site tracheal intubation was performed by auxiliary medical personnel. Success rate and complications. Chest. 1984;85(3):341-345. 5. Sakles JC, Chiu S, Mosier J, etc. The importance of first-time successful tracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71-78. 6. Caroline NL, Elling B, Smith M, etc.: Street First Aid, seventh edition. Jones and Bartlett study: Burlington, Massachusetts, 712-837, 2013. 7. Rosen P, Barkin R: Concepts and clinical practice of emergency medicine, fourth edition. Mosby: St. Louis, Missouri, 2-24, 1998. 8. Campbell JR: International Trauma Life Support for Emergency Care Providers, seventh edition. Prentice Hall: Saddle River, New Jersey, 108-86, 2011. 9. Joint Committee. (nd) Certification standards. Retrieved from on May 28, 2014. 10. Hulley SB: Designing a clinical study, third edition. Lippincott Williams & Wilkins: Philadelphia, 257-270, 2007. 11. Escot M, Gleisberg G, Traynor K, etc. Video and direct laryngoscopy: a multi-site review by the nursing staff of the four-month run-in period. Pre-hospital emergency care. 2014; 18: 123—162. 12. Escot M, Gleisberg G, Manson H, etc. Video and direct laryngoscopy: Evaluation of the EMS for the first 100-day run-in period. Emerg Med Aust. 2014; 26:1-16.