Removal of ETI from Paramedic scope – follow up

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Since the release of the clinical instruction (CL103) relating to the decision made to remove ETI from the Paramedic scope of practice (see this Need to Know Post) we have received lots of feedback, comments, suggestions, and questions. The most common theme in the feedback is the need for greater understanding to be provided on the decision and our anticipated next steps that are being worked up.

The decision to remove ETI is not as a result of any one incident, we have been reviewing ETI for a period of time, as have other Trusts nationally with some deciding to remove ETI from the scope of practice. Similarly, we have monitored international evidence and considered our professional bodies consensus statement (College of Paramedics).

Over the time of our review in EEAST there had been numerous mitigations put in place both regionally and locally to raise awareness and improve compliance and competency. These include elements such as the mandatory use of an airway log; airway cascade, ETCO2 and Corpuls refreshers on PU 2018 and 2019 taught opportunities; and other learning or CPD opportunities through podcasts, cardiac arrest bootcamps and local training events.

The decision for the immediate removal was a risk-based approach where the perceived benefits of intubation being undertaken by individuals did not outweigh the current risks being realised regionally - leading to patient harm, despite the actions above being undertaken.

The main issues that were being noticed were that of mis-placed or unrecognised oesophageal intubation, coupled with low compliance of documented ETCO2 use. In the two years of data collected to support the options being assessed, 18 reported incidents were investigated directly related to airway management, 11 of which were declared as Serious Incidents (SI). These related to a mis-placed ETI or unrecognised oesophageal intubation contributing to patient harm. Subsequently in the month prior to this clinical instruction, we had a further two reported unrecognised oesophageal intubations, one of which is a declared SI.

Clinical audit data has revealed that despite the use of ETCO2 being mandatory, there is poor compliance of use. An average of 15% of attempts had no documented ETCO2 to confirm placement over a one-year period. One month this was as high as 27%, i.e. over 1:4 ETI’s did not have ETCO2 applied. This equated to approximately 200 intubations that did not have ETCO2 used to confirm placement. Data has demonstrated that on average, Paramedics across EEAST were undertaking the skill less than once a year.

Airway log sampling undertaken only yielded a 65% return rate with a 28-day notice period as part of the annual 10% staff sample; despite guidance that submitting nothing, even if submissions were of limited quality, would record a ‘nil return’. 35% of Paramedics sampled could not demonstrate having an airway log.

The senior leadership team acknowledges and understands that in order for the skill to be used, there must be consistent access to training and access to simulated practice, but more importantly a system of quality assurance and review of currency and competency through: clinical review of airway logs demonstrating skill practice, professional discussion and simulated assessment coupled with improved quality metrics. This aspect of quality assurance and consistent regional training access will need to be improved moving forwards.

The actual and potential risk of harm to patients exists and is being realised. Our risk assessment demonstrates that it continues to be likely to happen again and meant that the removal of the skill from the Paramedic scope of practice could no longer wait until systems were developed and put in place.

Next steps
Any re-introduction will be on a phased approach, firstly to ensure sufficient measures are in place for competency assessment and ongoing currency assurance, continually meeting the required standards. All clinicians that will be undertaking the skill must be able to demonstrate regular exposure (real or simulated intubation >2/month for any category of patient the skill is used on), a high standard of knowledge of airway anatomy and the airway cascade, how to problem solve issues and emergencies,100% compliance with ETCO2 use and understanding relating to ventilation and waveform capnography. This would be initially assessed, reviewed monthly then re-assessed on an annual basis thereafter.

We are looking to re-introduce ETI Scope of practice to key groups of staff that attend cardiac arrests on a regular and targeted basis. Our aim is to ensure a resource that is available 24 hours a day, 7 days a week. This resource is yet to be confirmed and we are in discussion with operations and UNISON colleagues to confirm the resource that will be providing availability alongside Critical Care colleagues. 

This re-introduction must as a minimum meet the standards outlined above. Doing this within current structures will require considerable operational ownership and personal commitment from clinicians to make it happen and to provide assurance regionally of a consistent approach and standard. This will require balancing with other priorities such as statutory and mandatory training, essential care skills, compassionate conversations and, of course, our response to patients. 

With the implementation of a consistent Trust wide supervision and mentorship model and increased availability of clinical leadership roles at a local level to oversee this system, we could then re-assess the Clinical Instruction and associated risk assessment for continued relevance. 

We will do our best to answer your questions with FAQs to follow and progress this matter as quickly as possible. We are setting up a working group to review concerns raised and plan next steps but please be assured that the actions being taken are risk based and with patient safety staff welfare at the heart of the decisions.

Thank you

Chris Martin, Clinical Lead – Clinical Effectiveness

This clinical update can be downloaded as a PDF document below.


Published 13th October 2020





1 Comment
I'm confused as to the idea of reintroducing the skill to resources targeted to cardiac arrests. Surely a large amount of the evidence base leading to the removal of the skill and consensus statement was the airway 2 trial, which obviously suggested that it was inappropriate to use in such situations. Surley it should be on an individual competence based assessment, as apposed to circumstances leading to staff being able to apply it to objectively the wrong patients.
20 October 2020

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