Important update on airway management (updated)

Clinical Instruction

Following several adverse incidents relating to Endo-tracheal Intubation (ETI) that have resulted in Serious Incidents and the risk of harm, the Trust has reviewed all available evidence and made the risk based decision to remove ETI from the Paramedic scope of practice.

It is important to highlight that this decision has been taken to safeguard our patients and therefore the Trust will be implementing, with immediate effect:

Removal of tracheal intubation (Adult and Paediatric) as a paramedic competency; restricting it to those staff groups in a defined role:
Specialist and Advanced Paramedics in Critical Care

In the medium term, we will be looking to reintroduce intubation following a competency-based assessment for the following staff group:
Other defined role(s) targeted to cardiac arrests preferentially as agreed by the Clinical team and with access to the requisite infrastructure to support maintenance of competency.

The above is yet to be defined, but will be subject to implementing an infrastructure that can assure and govern those targeted staff groups to have provided adequate evidence of ongoing currency as well as successfully completing a competency-based assessment and will be in a position to maintain adequate evidence of training and skill maintenance.

There has been an amendment to the clinical instruction to reflect that that staff-side colleagues were informed of the decision prior to its release rather than in support of it.

The amended version has been uploaded to the document library and available below.

 

Published September 17th 2020

59 Comments
I would like to know what the trust is putting in place to safeguard our tracheostomy patients. What will the trust provide clinicians with to ensure that a patient with a blocked tube can be treated and ventilated appropriately.
Becky
02 October 2020


" GOLD STANDARD" airway management skill removed by the trust due to inability of a few.
I have over 30 years pre hospital care/ET experience , firstly with the Army Medical Services & University of Northampton , the later insisting on a min 30 tubes before being deemed "competent". Sadly many news paramedic's have been pushed though training at breakneck speed to get bums on seats & this is the result. Yet another nail in the coffin of this job.

Chris Martell
21 September 2020


Why are we in a cluster?

The introduction of I-gel which provided an effective airway in almost all cases made endotracheal intubation partially redundant.
The failure to ensure that’s NQP’s had an adequate exposure to develop and ended the skill ensured its demise.

Let’s be honest, ET intubation is gone.
Move on.

Mark
20 September 2020


Why has this skill been taken away before an actual plan on who to train up/practice this skill has been decided?

Why where those who did not follow the safe procedure for intubation have their competency removed - why a blanket ban for those of us practicing the skill safely?

Will you be training up more specialists in critical care? (Or will we continue to rely on HEMS & Other charities for these services?). They are not always accessible if already tasked to a job or not booked on.

What is the safety net for patients with pre-existing airway difficulties? or other special case patients?

I appreciate it is not a common skill to put into practice, however it has on a few occasions for me been the only option that has worked affectively. I do not attempt to tube if my igel is working however it concerns me loosing this important skill to all Paramedics without some sort of plan in place (relying solely on charities in the interim isn't the best idea in the world..)

I know I'm repeating a lot of what has already been said but as professionals are we not entitled to more details/answers/explanations at the time that the skill is removed from competency? I can't help but feel a little insulted at the lack of communication in regards to this.

Emma
19 September 2020


I think the Trust should have involved staff in the decision making, at least consulting with them. This would have been a more inclusive approach and ensured better transparency and engagement even if the outcome was the same. Staff and managers then should have been briefed beforehand and equipment removed at appropriate time.
Chris
19 September 2020


I would like to respond to the points made by Pauline.
Frankly, they're quite insulting and a little childish in the context of what is being discussed i.e. the potential to save a life when other methods have failed or are not appropriate.
To compare that to someone taking a ball away is pretty poor.
The collective "we" you talk about does not apply to those of us who have been abiding by the guidelines for the benefit of our patients and because we care about the outcomes for them.
I have no doubt that some paramedics have failed to follow best practice and that is for the Trust to address.
Please don't tar all of us with the same brush as it's insulting.
I have supplied the clinical leads with details of recent examples where intubation was the only option for 2 patients.

David
18 September 2020


Finally a decision on the subject! Well done to all those involved, although I agree that this hasn't been very well communicated.

Anyone suggesting that this announcement has been a complete surprise clearly have been lacking in Continued Professional Development, as the subject has been widely debated for a number of years now, with growing evidence against it being a routine skill.

Paediatric intubation should have been removed years ago - I don't know of any other ambulance service offering paediatric intubation as a standard Paramedic skill.

Please can we use this opportunity to replace all LMAs with paediatric iGels so equipment and practice is familiar when in these very stressful situations.

And please confirm to all MRO teams that the laryngoscope blades, magills and a tube for trachy replacement must remain available.

Graham
18 September 2020


It absolutely baffles me that the majority are more sad someone has taken their ball home than the actual harm we have done to patients.

Yes, it’s a shame, but we - the collective we - had the chance to avoid this, we knew the guidelines, the mandated rules, the requirement to keep current, the requirement to keep an airway log and we failed to adhere.

Patient safety must come first. The evidence of harm is factual, and readily available, as is national and expert opinion, this trumps the hypothetical 35 year old, pregnant female on the North Norfolk coast who has taken an overdose and drowned.

Pauline
18 September 2020


Comment from Chris Martin, Clinical Lead – Clinical Effectiveness.

Thank you for your comments and emails regarding the very difficult decision made to remove intubation from the paramedic scope of practice for EEAST. We have received a number of individual enquiries, as well as valued feedback regarding a number of important points and views.

We are reviewing all responses which will be included in a clinical forum which is being set up, staff will also be able to speak with the clinical team, further details will follow. We will also be producing a FAQ response to be posted on NTK, which will provide greater detail into the rationale for withdrawal.

We absolutely understand that this may feel like a negative development regarding clinical care you are able to provide patients, however, this has to be balanced with the potential of our patients coming to harm following unrecognised oesophageal intubation. We needed to take immediate action to safeguard future patients, and also to protect staff from potential moral injury of inadvertently causing harm to a patient. This has been a difficult conclusion for the whole team to reach, however, when faced with the body of evidence, this was the only defensible course of action.

We are currently planning how the Trust can enable competency based reinstatement of the skill and will communicate any developments as they happen.

Chris Martin
18 September 2020


It is now almost 30 years since I intubated my first patient "on the road" and have intubated hundreds since then. Probably more than a lot of Critical Care Paramedics have done.
Not once have I ever intubated their oesophagus and been unaware of that. That was long before capnography and bougies.
I fully buy into the need to adopt current best practice and I maintain my airway skills log accordingly. I even got signed off by one of the clinical leads.

You have made a decision to penalise hundreds of staff (and potentially thousands of patients) by removing the ability to perform a vital and life-saving skill and from those who have never done this incorrectly and follow best practice.
I imagine you will end up with far more "SIs" once Coroners learn that patients are dying from airway problems that could (but weren't) corrected.
I imagine that families will also consider expensive legal action against the Trust.
Why penalise everyone when you should be targeting the issues and individuals behind this?

David
18 September 2020


It absolutely baffles me that the majority are more sad someone has taken their ball home than the actual harm we have done to patients.

Yes, it’s a shame, but we - the collective we - had the chance to avoid this, we knew the guidelines, the mandated rules, the requirement to keep current, the requirement to keep an airway log and we failed to adhere.

Patient safety must come first. The evidence of harm is factual, and readily available, as is national and expert opinion, this trumps the hypothetical 35 year old, pregnant female on the North Norfolk coast who has taken an overdose and drowned.

Pauline
18 September 2020


Hi
lots of relevant points on here but management don’t seem to be responding what platform do these staff members have to use to get a senior management Response to such a key issue.

Adam
18 September 2020


I tried for 2 years to go back into theatres to do more intubations. The trust wouldn’t support it. I have the emails.

Anaesthetists weren’t happy for us to practice under their registration as we weren’t employed by the hospital or practicing as a student attached to a university. It was all about insurance.

Eventually I found the Collage of Paramedics would cover us insurance under CPD. I was meant to be going in April but Covid.....

The trust still didn’t support it. Why are the trust not supporting us in maintaining skills??

Sam
18 September 2020


Only the other day we secured a difficult airway in Downham Market with a tube. It was 20 mins before a second crew arrived, critical care were another 10mins behind them.

Is 30mins without an airway now acceptable???

Sam
18 September 2020


Very confused by this bizarre decision. How are our Paras supposed to maintain this skill working for a Trust which refuses to let them practice? Paras will have to choose between losing the skill and being trapped in EEAST forever or leaving now. Dorothy herself keeps talking to us about retention - how has senior leadership not recognised that this decision will blatantly lead to an even greater mass exodus of qualified staff than we already have? And what about the new SAPs? I struggle to believe the Trust would continue to fund the theatres placement if they no longer require their Paras to possess the skills? Will they replace this important feature with a 30minute lecture?

This decision creates so many urgent, career changing questions for us, and it’s a new low that the Trust chooses to announce this monumental decision in this minimal post without providing clear reasoning and effect.

We’ve been directed to post comments here rather than bother any actual managers - will anyone actually read them here I wonder.....

Cora
18 September 2020


So, rather than focus on ensuring staff competency, e.g. providing more training, updates, skills sessions, assessments etc, (Or even including practical and clinical skills in the PU, as used to be the case....) the Trust's reaction is to remove an option which has arguably saved more lives, (or at least allowed the possibility of them being saved...) than it has 'adversely affected'.
Unbelievable!!
I suggest that by placing emphasis on the i-gel as first line airway management, the Trust has effectively de-skilled paramedics, because intubation has now become a less used skill. (And i'm not disputing the validity of that decision, only highlighting a side effect.) So surely the remedy for that would be to create ways to improve the skill, not remove the option!

There is too much emphasis on filling the PU with government mandated training, alongside reducing the duration and frequency of the PUs to minimise abstraction from front line duties. We need to return to the days when the courses were every year, and were several days long and included these essential practical skills. We used to be re-assessed on what were then considered 'basics' such as intubation, cannulation, childbirth; as well as 'advanced' skills like chest decompression and needle crich's.
This is not a case of paramedics failing patients by improper application of a technique- rather it is the Trust failing paramedics, (and, as a result, patients,) by failing to provide adequate training and practice opportunities for such skills. :(

Jade
18 September 2020


Yet again the many are penalised due to the few.

As a service should we not be addressing the problem through education of those members of staff that clearly are not using Capnography.

If we don't start to look at those that can't do the job then you may as well take all advanced procedures away.

Neil
18 September 2020


"Several adverse incidents".....?
How many and in what time frame? Also how many successful Vs adverse incidents in the same date range?
Let's have some figures to back up your decision making so we understand the full extent of the alleged problem or is this yet another a knee jerk reaction without sufficient or correct data to back up the action taken?

Craig
18 September 2020


interested to know if Laryngoscopes & magill forceps will now be removed too?
Having this equipment available in the armoury can be vital in treating a deteriorated choking patient with a foreign body airway obstruction.
I also understand that AAP's and Technicians have undergone training in this skill recently

Mohammed
17 September 2020


Barry makes a very good point, a size 6 tube is a serious get out of jail for the failed trachiostomy pt... trust me on that!!

Policy politics aside are intubation kits going to be removed from the ambulances or will they remain as present but forbidden?
Tympanics walked out of the trust in their hundreds this year, might be worth giving G4S a buz now.

Jimmy Macintotaltosh
17 September 2020


Ridiculous change on the part of EEAST. The upper echelons have shown a complete disregard to the clinical competency of their paramedics and put patient's lives at risk with immediate effect.
Yes, by and large the i-gel is sufficient for most cardiac arrests, however if the airway is unstable due to vomiting, manual handling or oesophageal oedema it is not not enough.
I am shocked that rather than put together a regular training package/competency for paramedics, the skill has been removed altogether.
Unbelievable.

Nick
17 September 2020


please supply links to relevent SuI reports / learning from Incidents. To allow staff to understand the position the trust is coming from.
Keith mac
17 September 2020


what will we do if we are unfortunate to be at a cardiac arrest of a pregnant women in her third trimester with critical care 40 mins away ? Think a plan B needs to be implemented pretty quickly.
jen
17 September 2020


I would be very keen to know the number of SIs each year as a result of incorrectly placed tubes Vs the number of successful intubations.
Removing tubing as a skill may work in urban environments like London where you're 5 minutes from an ED and have good provision for advanced paramedics. However in our area I fear outcomes for patients will suffer.

Scott
17 September 2020


I think this is a retro step backwards we need this skill and just because of several incidents ( actually how many) compared with the successful ones that we do. Is this due to the university just letting the students watch this procedure rather than practice it correctly in theatres and get it signed off as being competent in this skill I really hope the trust will reverse this decision in due course when they realise the concern and upset this has caused to all the paramedics
Steve
17 September 2020


Can anyone confirm if can continue using the Lucas with an igel?
Mark
17 September 2020


Will HART paramedics still be able to tube?
Jacob
17 September 2020


So taking the stance of a few people who have made mistakes, take it always from everyone and not just retain the people who made the mistake!!!! What happens when critical care refuses to come out as the patient is too old for them to worry about and they want to wait for a better job (this did actually happen) so critical care mostly finish at 0200 and very rarely work a full night shift, note to self don’t have an arrest, a drowning, serious airway burns after this time, best wait until the morning once critical care have got up. Why not retain every year instead of on pu letting paramedics use igel to save time on pu day make them intubate and sign them off or they spend a day in theatres every year! Patients will die because of this decision, the press will have a field day
Mark
17 September 2020


Just another 2pence worth. Will we not get an increase in SIs for when we should have intubated but didn’t because no ‘ specially trained staff’ were Available? I for one would feel I had let a patient down knowing I could have done more, I just wasn’t allowed to.
Simon
17 September 2020


This isn't good enough; as paramedics we are responsible for ensuring we are familiar and compentant with ALL aspects of our scope and those who have not been should be reviewed and treated accordingly by the trust and hcpc.
Patients will suffer as a result of this decision. I intubated a 56 year old last week where supraglottic device or needle cric would have been ineffective due to the vast amounts of fluid in his airway. Despite the odds we got rosc, although ultimately there was a poor outcome.
The trust should be supporting us as autonomous clinicians, not forcing us to not give the patients to gold standard care they deserve

Katie
17 September 2020


So taking the stance of a few people who have made mistakes, take it always from everyone and not just retain the people who made the mistake!!!! What happens when critical care refuses to come out as the patient is too old for them to worry about and they want to wait for a better job (this did actually happen) so critical care mostly finish at 0200 and very rarely work a full night shift, note to self don’t have an arrest, a drowning, serious airway burns after this time, best wait until the morning once critical care have got up. Why not retain every year instead of on pu letting paramedics use igel to save time on pu day make them intubate and sign them off or they spend a day in theatres every year!
Mark
17 September 2020


I’m not surprised to see this at all, nor am I particularly disappointed. My experience of intubation has always been that it has completely deflected everyone’s attention away from the core basics of a cardiac arrests as people tend to become so focused on who’s going to do the tube. Just an idea though and I’m not sure if this is what they are implying that may be introduced in the medium term... but perhaps it would be helpful if our LOM’s were able to do tubes for us, in situations where we really need a patient to be intubated? Surely it’s really unlikely that you would find yourself in a situation where the only way to manage a patient’s airway is with a tube, and ALL critical care/specialist paras AND LOM’s would be unavailable (if LOM’s are given the responsibility to be able to intubate).
Amanda
17 September 2020


Yet again we all suffer the incompetence of the few.
Stuart
17 September 2020


It is interesting to see the comments within this thread. Some clearly emotional responses, but some rather balanced.

Many frequently discuss the ‘special circumstance’ however, in reality this is a rarity. Even in this situation, and I speak from experience as an active clinician a SGA, well sited taking time to optimise with positioning is actually effective in oxygenation and ventilation, and tracheal intubation can be achieved (even with a slight delay).

A balanced risk based approach, that considers international evidence including RCT, with EEAST audit of activity/compliance with EtCO2 and review of reported incidents demonstrates, in my opinion, a deeply considered yet difficult decision for the Trusts senior leadership and executive team. A decision that has our patients and staff at the forefront.

I remain a proud employee, practicing clinician within EEAST.

Ash
17 September 2020


Can I ask how many SI's have been raised in order for the trust to take this action. I understand ET tubes are not used very frequently but it is sometimes necessary and CC are not always available. to down skill everyone because of a few seems a bit extreme and will potentially put lives in danger. I could understand the trust doing this as a temporary measure until all have passed a competency assessment but to down skill permanently is wrong.
James
17 September 2020


For me a terrible decision by the trust and one that I take very personally, Intubation is a skill I achieved and have been very proud to have been able to perform for the last 28yrs and to have it Just taken away from me does make me, well just very angry, As one of the trust Paramedics targeted at cardiac arrest on a regular basis I have had the opportunity to fall back on those many years of experience to assist and support crews by providing gold standard Airway support when needed at any time. Personally, I can only hope that I fit into one of the so call OTHER DEFINED ROLE (s) that will allow me to continue to provide a skill that I’m incredibly proud to have achieved. A very sad day for the profession in EEAST
Neil
17 September 2020


The dissemination of this decision leaves wanting to say the least. Based on evidence this is not the wrong decision and LAS removed this skill a long time ago. However, to remove when there is absolutely no commissioned critical care pathway is ridiculous. Relying on HEMS / BASICS CCPs to manage these airways now.
Thankfully, we have loads of Advanced Paramedics in Urgent Care out there now to help intubate.....oh wait

Liam
17 September 2020


I also work as a resuscitation officer in hospital . Spending time in theatre to maintain skill
Can provide log sheets .
Disappointed I will no longer be able to use this skill

John
17 September 2020


Another retrograde step and knee jerk reaction to some isolated incidents as we continue to see from many decisions made by the trust. How many successful intubations have there been in the same period? Context is important here. Please could the trust advise how we are to manage airways in special circumstances? Will we have to revert to needle cric? That’s used and practiced even less than intubation. There’s a retention issue at EEAST and this will not help the situation, perhaps rather than just announcing this it would have been better to put some supportive training in place at the same time. All RRVs are targeted to cardiac arrests so will intubation now be a pre-requisite skill for being on an RRV? Maybe this will stop the issue of non-paramedics being on cars who then call for patients to be transported to then have a paramedic arrive on a vehicle, assess the patient and then find they don’t need to be conveyed. Will intubation kit still be carried on all vehicles or will it be personal issue to the staff you are restricting this to? If a patient dies because an airway couldn’t be secured with an i-gel and no critical care resource was available what support will the trust give to the paramedics involved on a personal level? at an inquest? Infront of the HCPC?
David
17 September 2020


Another clear demonstration of a trust that doesn't allow their staff to practice and develop. Look out for the influx of SI's for when rapid intubation would save a life but isn't done. Or are we all going to be trained up to CCP's or ACP's? Of course not. Expect another large exodus of staff. Covering backsides and bums on seats again.
Ben
17 September 2020


people crying about not being able to tube, its an unnecessary rarely successful and hardly used procedure. As a paramedic I can count on one hand the amount of times I've tubed and had a successful outcome when 99.9% of the time an I-GEL is perfectly adequate and successful. I for one say its about time its been removed.
Elliot J
17 September 2020


Any plans on ditching the triage system...

Because that isn’t effective either?

Scott
17 September 2020


While I gels do a very competent job of maintaining an airway, they are not perfect. If you need to extract someone from a difficult situation, a tube is much more secure.
For once could we not look at individual cases and review training, rather than these blanket actions?
Something similar happened years ago with carry sheets, a very useful piece of kit indeed......

Jason
17 September 2020


Are we going to be removing needle cric as well then? as that's used a lot less and is much less effective. As mentioned in the comments, it's a nice THEORY to say they'll be critical care paramedics dispatched soon, but what if they're not available? it's a running job? Critical care will still be left to the charity model.
Jonathan
17 September 2020


As you said other trusts have gone this way too.... Only difference is those other trusts have an established critical care paramedic training route with a good amount of CCP's on the road. We at EEAST rely on charities for that capability which just shows how much EEAST want to further develop their staff!!

I know of several paramedics that have left EEAST for other services because they offer Critical Care pathways

Ben
17 September 2020


Absolute nonsensical madness from the trust yet again. Paramedics are being de skilled purely based on the fact that EEAST refuse to give proper training and education to their staff, as bums on seats is more important.

I just pray that I as a Paramedic am never put in a position where I have to watch a patient deteriorate and die in front of me because of a decision made by a group of people who are probably so far removed from life on the frontline, they wouldn't know what an ET tube was if it jumped up at them.

Tom J
17 September 2020


A lot of paramedics have requested for updates / assessment or more training on intubation whilst doing yearly PU. However this has never been done by the trust.
Majority of the time, Critical care are travelling long distances especially as by road at night time and again the trust has not thought about this appropriately. If personal have not been intubating by guidelines then surely those individuals should be given more training and assessments to bring up to the standard or even improve on the standards and not take every ones skills away because of others.

James
17 September 2020


Does this mean that you will be providing a critical care progression pathway for your staff? Critical care is very often not available for the jobs where there will be a significant impact from this change.
James
17 September 2020


Does this mean we will be getting more critcal/specialists paramedics available 24/7
James
17 September 2020


Little bit upsetting, as already pointed out. What about special circumstances. I will paint a picture north Norfolk coast 2 o’clock in morning, patient witnessed to go underwater for prolonged period, is pulled out, CPR started.... Closest CCP is Norwich airport or not available, no BASICS charity available what do I do in regards to definitive airway? Why ‘de skill’ us, why not get us re certified 6 monthly, for those that have the skill. It would be easy to update CAD to identify ‘tube qualified’ or TQ same as wound closure.... just my 2 pence worth.
Simon
17 September 2020


I know igels are really useful for most arrest situations, but what we do during an arrest where the patient had an asthma attack, has severe burns/ trauma, has a very high BMI, or their end tidal co2 just isn’t being affected by igel ventilations...if we have no HEMS, no BASICS, no AP/ CCP’s available then how do we manage the airway without being able to upgrade to intubation?
Sam
17 September 2020


Could we take A pioneering approach, as a trust with access to world renowned trauma and critical care pathways, temporarily removing from practice and inputting a training and development structure that means our paramedics could safely intubate, providing the opportunities to maintain an airway log, supporting our autonomy as advanced life support providers?
Js
17 September 2020


'As per the consensus recommendations, once a safe, well-governed system of continual
training, education and competency is in place and upon review of the evidence and
compliance data, we will review this decision and if supported would look to implement
the skill back as standard scope of practice for all Paramedics.'

So are the Trust taking steps to implement a 'well governed system of continual training...'?

Or is it going to be the case that the Paramedic scope within the Trust is going to regress because they are unwilling to facilitate appropriate training and education?

Staff for a very long time have requested better support for training and education but it feels this is never addressed and instead the decision is taken to remove elements of practice.

James
17 September 2020


I fully agree with this move. Intubation was first introduced when there was simply no alternative. Its too dangerous unless you are well practiced in it.
John
17 September 2020


The College of Paramedics had issued a consensus paper on maintaining ETT skills in April 2018. Is it not preferential to support working groups in maintaining this vital intervention for patients that are indicated for it?
https://www.collegeofparamedics.co.uk/COP/Professional_development/Intubation_Consensus_Statement_/COP/ProfessionalDevelopment/Intubation_Consensus_Statement_.aspx?hkey=5c999b6b-274b-42d3-8dbc-651c367c0493

Ben
17 September 2020


My only question is, how many critical care paramedics do we have currently employed by EEAST.... I've seen one on the road in 4 years!
Ben
17 September 2020


Utterly disgusting and shocking, but hardly surprising. Yet again as a trust you demonstrate that autonomy and clinical excellence is not what your about, but rather covering yourself and risk aversion. The people who have decided for this will never know what it would feel like for a frontline paramedic to be watching a burns patient or anaphylaxis patient swell to the point their airways closes and know they can do nothing about it, or a major trauma patient with significant facial destruction choke to death on their own blood and desperately suctioning when they know they should be tubing but can’t. Frankly it is no wonder we haemorrhage so many paramedics to other, more supportive and progressive, trusts. But I know I’m wasting my energy here too, because there’s no way this lump of honesty will be moderated for the public eye.
Steve
17 September 2020


Will you be providing supporting information on which patients we should be requesting critical care support for to perform ETI?
Warren
17 September 2020


I knew this was going to happen but sad to see it go especially as not many critical care available when I have needed them. Also how does this fit with the U.K. resus council statement for special circumstances arrest such as drowning, pregnancy and anaphylaxis and if I was not able to intubate the patient we would have not been able to ventilate the patient.

Would it not be better to annually review competency during PU, also does this mean airway log are now redundant and will a size 6 tube still be in place as previously had to insert one in a laryngectomy pt.

Barry
17 September 2020


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