Airway Management Proficiency Checklist for Assessing Paramedic Performance

Figures & data

Table 1. Example of a deconstructed, step-wise, comprehensive airway management approach and categorization, with observable items of behavior and potential scoring determinants^1,2

Airway Management Category	Observable Items	Scoring Determinants
Indications for active airway management and invasive ventilation	Crash vs. emergent; team members, respiratory failure, BiPAP,^* protect airway, altered consciousness, be PREPARED (Positioning, Room, Equipment, Pharmacy, Airway, Ready, Early, Don'ts)	Recognizes and acts: crash vs emergent; Equipment and drugs correct and ordered; Position and team
Establishing airway, suctioning, optimizing supplemental oxygen delivery	Open airway, maintain patency, remove debris, suctioning, maximize pre-02,^† assisted ventilation, and 02^† supplementation	Opens and maintains airway patency; Suctions effectively and safely; Maintains O2,^† SpO2^† max, aspiration
Optimizing positioning of patient, equipment, assistance	Upright, stretcher height, airway assistant, respiratory therapy, obese pt., ETT ready	Optimal positioning, team assembly Identify high risk patient ETT optimized
Emergency sedation^‡ and neuromuscular blockade	Choices, contraindications, dosages, delivery, timing, waiting	Dosage, timing, i.v. problems
Laryngoscopy and endotracheal tube (ETT) placement	DL^§, video-laryngoscopy; placing tube, bougie, 30 seconds, first attempt, assistance, unable- 02^†monitor, repeat,	Insertion, forcing, damaging, timing; First, 2nd, or 3rd attempt, steps
Difficult airway approaches and actions	Backup airways and personnel, supra-glottic airway, alternatives, cricothyrotomy	Cardiac and chest complications, secondary airway utilization, cricothyrotomy
Confirmation of ETT secure and placement.	Breath sounds, EtCO2,^║ SpO2,^# Hold, tape, other	Rapid, proper steps, always secure
Post ETI considerations.	Critically ill patient, ventilator settings	6 mL/kg; PEEP,^** airway secured and patient still sick

^* Bilevel positive airway pressure.

^† 02 is supplemental oxygen.

^‡ Sedation and neuromuscular blockade were not included.

^§ DL is direct laryngoscopy.

^║ EtCO2 is end-tidal carbon dioxide.

^# Sp02 is saturation of O2 detected by pulse oximeter.

^** PEEP is positive end expiratory pressure.

Table 2. Number of items retained at each stage of item analysis with number of items dropped (in parentheses) and rationale for decision to drop items

		Stage of Analysis
Subscale	Items	1	2	3	Final
Backup Airway (35)	Dropped	14	0	1	8
		-Q (3)		-Q (0)	-Q (6)
		-D (3)		-D (1)	-D (1)
		-S (8)		-S (0)	-S (1)
	Retained	21	21	20	12
Intubation (62)	Dropped	20	6	9	10
		-Q (1)	-Q (1)	-Q (5)	-Q (6)
		-D (0)	-D (2)	-D (3)	-D (4)
		-S (19)	-S (3)	-S (1)	-S (0)
	Retained	42	36	27	17
Suction (9)	Dropped	9	0	0	0
		-Q (9)
		-D (0)
		-S (0)
	Retained	0	0	0	0
Ventilation (21)	Dropped	8	2	0	3
		-Q (2)	-Q (1)		-Q (2)
		-D (0)	-D (0)		-D (1)
		-S (6)	-S (1)		-S (0)
	Retained	13	11	11	8
TOTAL (127)	Dropped	51	8	10	21
	Retained	76	68	58	37

Q = Qualitative reason; D = Duplicate item; S = Statistical reason.

Qualitative reasons for dropping items included tasks that were considered to be not fairly assessed in the clinical scenario, items that were poorly worded, and items that were considered high inference (task was difficult to observe or required to much interpretation). Duplicate items were dropped when the other items of a similar nature were found in the instrument. Statistical reasons involved items that had low correlation with the outcome items (R_tet ≤.18); had poor internal consistency as measured by the scale KR-20 with R_pbis ≤.20); and poor statistical fit with the Rasch Model (Mean Square Infit and Outfit values of less than 0.5 or greater than 1.7).

Table 3. Airway Management Proficiency Checklist Instrument (37 items with 3 performance standards) listed by subscale and original reference numbers

Scale - Item No.	Performance Task	YES	NO
V-5	Inserts oropharyngeal (adjunct) airway
V-7	Chooses correct adjunct airway size
V-9	Inserts adjunct airway to proper depth
OV-11	Ventilates patient immediately (w/in 30 sec) with BVM unattached to oxygen
V-15	Ventilates patient at rate of 10–12/min
V-16	Observes BVM technique for 30 seconds: Evaluates volumes (visible chest rise)
V-19	Orients mask correctly
V-20	Uses thenar eminence technique (E-C grip)
V-21	Maintains C-spine precautions during BVM
I-31	Uses straight-to-cuff stylette curvature technique
I-33	Checks equipment for cuff leaks
I-36	Positions head properly
I-40	Grasps laryngoscope with left hand
I-47	Elevates mandible from 45–90 degrees w/laryngoscope
I-55	Flips up epiglottis to expose larynx
I-57	Inserts laryngoscope to appropriate depth
I-58	Moves blade tip smoothly without shaking or jerking
I-61	Maintains view until ETT has stopped advancing
I-67	Passes ETT through cords with limited or no impingement
I-68	Passes tube through cords (laryngoscope in mouth to tracheal placement) in ≤20 seconds
I-70	Disconnects syringe IMMEDIATELY after inflating cuff of ET tube
I-72	Listens over each lung
I-75	Checks end-tidal CO2- After ET Tube placement
I-78	Checks pulse oximeter-After ET Tube placement
I-80	Maintains control over ET tube placement
I-81	Secures ET tube (with device)
OI-84	Successfully intubates within 1 attempts
B-106	Recognizes need for backup airway
B-108	Identifies an appropriate backup airway device
B-110	Checks equipment for cuff leaks
B-114	Immediately inflates cuff, prior to ventilation
B-117	Immediately disconnects syringe after inflating cuff
B-119	Confirms proper placement by auscultation bilaterally over each lung-Backup airway
B-121	Checks end-tidal CO2-after Backup airway placement
B-123	Checks Pulse Oximeter-after Backup airway placement
B-126	Appropriately positions equipment needed for backup airway
B-127	Maintains control over ET tube [or backup airway] after placement
B-128	Secures ET tube (or backup airway device)
B-129	Introduces ET tube or backup airway and advances to proper depth
OB-130	Successfully places backup airway within 1 attempt

O = Outcome Performance Standards; V = Ventilation; I = Intubation; B = Back-up Airway.