By Rob Lawrence; Maia Dorsett, MD, PhD
How do we really know if we鈥檙e 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鈥檛 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鈥檛 been measuring our performance on a broad scale 鈥� 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鈥檚 鈥�2024 Measures Report 鈥� Enhancing Airway Management One Measure at a Time鈥� 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: 鈥淭he 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.鈥�
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 鈥� 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, 鈥渢he 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%).鈥�
It鈥檚 easy to say this is just a documentation problem, but it鈥檚 not. Missing vital signs aren鈥檛 random 鈥� they鈥檙e likely an indicator that there鈥檚 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鈥檚 room to improve first-pass success rates and minimize hypoxia and hypotension.
The , 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鈥檝e 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鈥檛 about accepting low performance 鈥� it鈥檚 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鈥檒l 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.
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.
