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A wake-up call on airway management

Lessons and goals for advancing airway care from the NEMSQA Airway Measures Report

Respiratory system and lungs anatomical structure

Our lungs remove the oxygen and pass it through our bloodstream, where it’s carried off to the tissues and organs that allow us to walk, talk, and move. Our lungs also take carbon dioxide from our blood and release it into the air when we breathe out.Anatomically, respiratory tract is divided into upper (organ outside thorax - nose, pharynx and larynx) and lower respiratory tract (organ within thorax - trachea, bronchi, bronchioles, alveolar duct and alveoli).

Jitendra Jadhav/Getty Images

By Rob Lawrence; Maia Dorsett, MD, PhD

How do we really know if we’re doing a good job in EMS? And once we know, how do we prove it and improve upon it? These questions are at the core of our profession, and we can’t answer them by looking at one patient at a time. Instead, we need to take a step back and look at the bigger picture. Are our airway management strategies effective, safe and genuinely making a difference in patient outcomes? For many, the answer is still up in the air, simply because we haven’t been measuring our performance on a broad scale – at least not yet.

To tackle this challenge, the National EMS Quality Alliance (NEMSQA) has stepped up to the plate with a set of evidence-based quality measures designed to improve EMS performance and, more importantly, patient care. These measures cover critical areas like clinical effectiveness, patient safety and the patient experience itself. Using standardized definitions that map directly to NEMSIS fields, they give individual EMS agencies, regions and states a way to measure and enhance their performance. And on a national scale, they help us identify variations in care and highlight best practices to improve what we do. Recognizing how vital airway management is to prehospital care, NEMSQA has focused on quality measures in this area. NEMSQA’s “2024 Measures Report – Enhancing Airway Management One Measure at a Time” gives us a first look at national performance data pulled from the NEMSIS 2023 dataset, showing us where we stand.

| More: Quality as an organizational strategy

What did we measure, and what did we find?

In the introduction to the Airway Measures report, NEMSQA President Michael Redlener sums it up well: “The National EMS Quality Alliance has drawn on all the available evidence and best practice guidelines, and collaborated with experts across the field of prehospital emergency medicine to crystallize a set of quality measures that reflect a simple yet profound attention to the aspects of airway management that contribute to a positive outcome for patients. Our mission is to create measures that enable EMS to understand what good looks like, measure it, and aim towards a goal worthy of our roles and responsibilities.”

The report covers six airway measures, from basics, like respiratory assessment and oxygen administration for hypoxia, to improving SpO2 for patients in respiratory distress. It also dives into more advanced topics, such as first-pass success with invasive airways, proper pre-oxygenation before intubation, and the percentage of first-pass successes without hypotension or hypoxia during the peri-intubation period. Performance varied across the board – some of the gaps could be chalked up to documentation, but there are opportunities to elevate clinical care.

One of the most complex measures, Airway-01, really drives this home by focusing on first-pass placement success (FPS) without hypotension or hypoxia.

Airway-01: Breaking it down

The Airway-01 measure tracks patients who had at least one endotracheal intubation attempt following a 911 response, excluding cardiac arrest cases and attempts made before EMS arrival. To meet this measure, several criteria need to be satisfied:

  • The first ETI attempt must be successful
  • At least one SpO2 and SBP reading needs to be documented during the peri-intubation period (3 minutes before and 5 minutes after)
  • There must be no instances where SpO2 drops below 90% or SBP falls below 90

Why does this matter? Because evidence tells us that this impacts morbidity and mortality. Failed first-pass attempts correlate with lower survival rates and more adverse events, while hypoxia and hypotension around intubation increase the risk of cardiac arrest and worsen outcomes in traumatic brain injury patients.

In 2023, national performance for Airway-01 was far from a success story: 21.4% overall, 21.2% for adults (49,129 records) and 28.9% for pediatrics (1,750 records). The report notes, “the most common reasons for failure were missing vital signs (SBP/SpO2) (54.8%), unsuccessful ETI on the first attempt (36.2%), followed by hypoxia/hypotension (9.0%).”

It’s easy to say this is just a documentation problem, but it’s not. Missing vital signs aren’t random – they’re likely an indicator that there’s no standardized process or checkpoint to verify that intubation conditions are optimized for critically ill patients. To address this, we need to standardize the process, making sure these checks are a priority in every intubation, not just focus on improving paperwork, as Fort Worth EMS has demonstrated. Beyond that, there’s room to improve first-pass success rates and minimize hypoxia and hypotension.

The NEMSQA EQUIP Airway Collaborative, a national airway management quality improvement project involving more than 50 EMS agencies and regions, will be an essential part of figuring out how we can do better with this measure and others across different systems.

Where to aim our airway efforts

The NEMSQA Airway Measures Report has given us a wake-up call on airway management in EMS. We’ve got a lot of work to do, and the data makes that clear. But it also gives us a starting point, showing us exactly where to aim our efforts. Improving airway management isn’t about accepting low performance – it’s about taking the information we have and using it to drive change. By focusing on standardized processes, embedding essential checkpoints into our workflow and leaning on quality measures, we can make real strides. And with the lessons learned from the NEMSQA EQUIP Airway Collaborative, we’ll have the insights we need to close the gaps. The goal is straightforward: keep pushing EMS forward to a higher standard of care, one airway measure at a time.


In a deep dive into NEMSQA’s 2024 report, Dr. Jarvis discusses critical airway safety measures and how EMS providers can leverage data, protocols and collaboration to achieve safer, more effective care

ABOUT THE AUTHOR
Maia Dorsett, MD, PhD, is an emergency medicine and EMS physician and educator. She completed her EMS fellowship at Washington University before moving to Rochester, New York, where she now serves as the medical director for EMS education at Monroe Community College and is the associate regional medical director for education & quality for the Monroe-Livingston Region. She is also the medical director for Gates Volunteer Ambulance. Nationally, she serves on the board of the National Association of EMS Physicians and the National Registry of EMTs. She is involved in quality improvement implementation and education, serving as the co-course director for the NAEMSP Quality & Safety course. Dr. Dorsett is also the medical director of Prodigy EMS.

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.