Advanced airway management (AAM) is one of the mainstays of emergency out of hospital care for acutely ill or injured people. As an essential area of competence for paramedic practice it is crucial paramedics are educationally prepared and supported to use the most efficient and effective airway management devices and techniques available to them. Within AAM practice the ability to perform laryngoscopic tracheal intubation is a critically important clinical skill and is an area of practice held in extremely high regard by paramedics. Nevertheless, it is a difficult skill to perform and maintaining competence is challenged by the infrequency with which it is performed by paramedics in the field (Bledsoe, 2006). Historically, most paramedics undergo in theatre training to learn about advanced airway management using the laryngoscope however a number of factors have necessitated alternative approaches be explored. First, the workforce demands and changing intheatre practices has significantly limited the opportunities for paramedics to participate in in-theatre advanced airway management training. Second, in-theatre training was typically delivered by anaesthetists who, although recognised experts in advanced airway management in controlled acute care environments, may have little experience managing airways in out of hospital situations and settings. Third, advances in airway management design means new devices are now available for airway management that may be more suited to emergency airway management in out of hospital situations and the intubating laryngeal mask airway (ILMA) is one such example.
The ILMA has been introduced to paramedic practice in Tasmania. Although easy to use, with proven efficacy (Agro et al, 1998; Choyce et al, 2000; Martel et al, 2001; Young, 2003; McCall et al, 2008), acceptance of the ILMA by out of hospital practitioners as an alternative to laryngoscopic tracheal intubation has been slow. Understanding the factors that affect the implementation of new AAM techniques, such as the ILMA, into paramedic practice is urgently needed to better inform the education and support needs of paramedics. With this goal in mind, the research reported in this paper focused on examining key factors associated with paramedics’ attitudes towards the ILMA and sought to measure their self-reported confidence and competence in its use for advanced airway management.
The study was undertaken in Tasmania, which is a small Australian state (68 119 km2; population 510000) with a three tier ambulance service as the sole provider of the state-wide emergency medical response. The service has 255 salaried paramedic personnel and 49 stations that respond to approximately 70000 incidents a year, (Commission, 2011). These paramedics must therefore be competent and confident in AAM for effectively responding to emergency airway management scenarios that often occur in isolated settings. Ensuring safe and effective AAM in any geographical context is foundational to successful paramedic practice. To this end the ILMA was introduced on a trial basis to Tasmanian paramedics. The Pre-Hospital Intubating Laryngeal Mask Airway Trial (PILMAT) was conducted between 2005 and 2006 to test the efficacy of the ILMA in airway management (McCall et al, 2008). Tasmanian paramedics who participated in this initial trial were invited to participate in this study that aimed to elicit the paramedic-reported factors affecting the implementation of the ILMA into paramedic practice with focus on educational practices.
Methods
The study was conducted to fulfil the requirement of a master of medical science by research. Ethics approval for this study was obtained from the University of Tasmania Human Research Ethics Committee (Tasmania) Network with approval number H9503.
It used a sequenced exploratory descriptive research design and elicited data through a questionnaire (comprising 5-point Likert scale) and semi-structured interviews. A total of 88 paramedics who had participated in the PILMAT trial were invited into the study and sent a questionnaire.
The questionnaire collected data relating to confidence, competence, experience, skill maintenance and perceived importance of selected advanced skills including laryngoscopic and ILMA tracheal intubation. Demographic data including qualifications and years of experience was also collected. The questionnaire was validated through a pilot and distributed by a third party to the participants and a 40 % response rate (n=35) was achieved. From frequency distribution and cross tabulation with Chi Square tests, four lines of enquiry emerged from the quantitative data analysis that required deeper interrogation.
Using a purposive sampling (Polit and Beck, 2008) technique, five paramedics participated in a one hour semi-structured interview to elicit more in-depth information about AAM, ILMA training, ILMA use and skill maintenance. The audio tapes from the interviews were transcribed verbatim to create texts that were thematically analysed using a standard coding and cross comparison technique.
Results
In terms of the demographic profile of the study participants, 80 % of the paramedics worked from an urban ambulance station. Overall, 86 % of the study participants were classified as intensive care paramedics and 26 % were clinical support officers. In terms of specific educational preparation for AAM, 25 % of the study participants had additional AAM qualifications and 80 % had performed ILMA tracheal intubation in the field.
Although the paramedics’ experience in AAM varied, all the paramedics had at least one year of experience and 54 % had over four years experience in the out of hospital clinical setting. Overall, the mean length of AAM experience for the study participants was 6.3 years.
Tracheal intubation as an essential AAM skill
A summary of paramedics’ perceptions of skills for paramedic practice, presented in Table 1, shows the majority of participants (94.1 %) reported tracheal intubation to be an essential paramedic skill. It was considered as essential as chest decompression and as important as defibrillation, intravenous cannulation, external cardiac compression and intraosseous cannulation.
| Agree | Disagree | Missing | P value | |
|---|---|---|---|---|
| Defibrillation | 100% (35/35) | 0.0% (0/35) | 0.0% (0/35) | * |
| Intravenous cannulation | 100% (35/35) | 0.0% (0/35) | 0.0% (0/35) | * |
| Intraosseous cannulation | 96.9% (34/35) | 0.0% (0/35) | 2.9% (1/35) | * |
| Chest decompression | 94.1 % (33/35) | 0.0% (0/35) | 5.7% (2/35) | * |
| External cardiac compression | 100% (35/35) | 8.6% (3/35) | 0.0% (0/35) | * |
| External cardiac pacing | 85.6% (30/35) | 2.9% (1/35) | 5.7% (2/35) | * |
| Cricothyroid puncture | 91.2% (32/35) | 2.9% (1/35) | 5.7% (2/35) | * |
| Rapid sequence intubation | 85.6% (30/35) | 8.6% (3/35) | 5.7% (2/35) | * |
| Tracheal intubation | 94.1 % (33/35) | 0.0% (0/35) | 5.7% (2/35) | * |
* P value not possible due to insufficient data and therefore <5 distribution in some categories.
1. In order to focus on only those who responded positively either by agreed or strongly agreed, the Likert scale data from the questionnaire was dichotomised into agree or disagree categories, agree and strongly agree were combined into the agree category and unsure, disagree and strongly disagree combined into the disagree category.
Confidence with tracheal intubation
The majority of respondents reported feeling confident in performing both laryngoscopic and ILMA tracheal intubation. However, the majority (80 %) of respondents indicated a higher level of confidence performing tracheal intubation using the ILMA than using the laryngoscope (63 %) as reflected in Table 2, which summarises the respondents’ level of confidence with different aspects of AAM.
| Agree | Disagree | Missing | P value | |
|---|---|---|---|---|
| Laryngoscopic tracheal intubation | 62.8% (22/35) | 28.6% (10/35) | 8.6% (3/35) | .034 |
| Paediatric tracheal intubation | 34.2% (12/35) | 57.0% (20/35) | 8.6% (3/35) | .157 |
| Cricothyroid puncture | 22.8% (8/35) | 68.4% (24/35) | 8.6% (3/35) | .005 |
| Tracheal intubation of an adult HI GCS5 | 51.3% (18/35) | 39.9% (14/35) | 8.6% (3/35) | .480 |
| Confirming tracheal tube position | 91.2% (32/35) | 2.9% (1/35) | 5.7% (2/35) | .000 |
| Manage the difficult airway | 85.5% (30/35) | 11.4% (4/35) | 2.9% (1/35) | .000 |
| Manage ‘can’t intubate can’t ventilate’ patient | 34.2% (12/35) | 59.9% (21/35) | 5.7% (2/35) | .117 |
| ILMA insertion | 94.1% (33/35) | 5.7% (2/35) | 0.0% (0/35) | .000 |
| ILMA tracheal intubation | 79.8% (28/35) | 11.4% (4/35) | 8.6% (3/35) | .000 |
Note: p values relate to chi-square analysis performed without the missing category in each variable.
Table 2 also shows the paramedics felt least confident performing cricothyroid puncture (23 %), paediatric tracheal intubation (34 %) and also in managing the ‘can’t intubate can’t ventilate’ patient situation (34 %).
There are higher reported levels of paramedic confidence for laryngoscopic tracheal intubation (63 %), tracheal intubation of an adult head injury with a Glasgow Coma Score of 5 (51 %) and ILMA tracheal intubation (80 %). Paramedics report greatest confidence in ILMA insertion (94 %) and although not statistically significant paramedics who were confident in laryngoscopic tracheal intubation were found to be 1.14 times more likely to be confident in ILMA tracheal intubation than were paramedics who were not confident in laryngoscopic tracheal intubation (95 % CI 0.81, 1.59). When this result was interrogated at interview, one of the AAM qualified paramedics explained past training in similar supra-glottic devices had increased their confidence in the use of the ILMA, because:
‘I felt very confident on my first use of it I don’t know if that is because I have put lots of standard LMAs in as well, but yes I had no concerns at all about putting it in.’
Just over half of respondents qualified in AAM, however, laryngoscopic tracheal intubation was reported to be both easier and quicker to perform than ILMA tracheal intubation as summarised in Table 3.
| Agree | Disagree | Missing | P value | |
|---|---|---|---|---|
| Easier | 46.6% (14/30) | 53.3% (16/30) | 0.0% (0/30) | 0.715 |
| Quicker | 43.3% (13/30) | 56.7% (17/30) | 0.0% (0/30) | 0.465 |
| Requires less training | 80.0% (24/30) | 20.0% (6/30) | 0.0% (0/30) | 0.001 |
Note: P values relate to chi-square analysis performed without missing category in each variable.
1. AAM qualified paramedics’ n=30
When asked to rate their confidence prior to performing the first out of hospital laryngoscopic tracheal intubation, 37 % of respondents indicated they were confident to perform this skill. This is in contrast to the result that shows over 51 % of respondents were confident in performing their first out of hospital ILMA tracheal intubation, which suggests there is some correlation between paramedics confidence and their educational preparation.
The study acknowledged that confidence is merely a pattern of thinking and alone does not necessarily mean paramedics are competent at performing tracheal intubation. For this reason, specific measures of competence, which were more than just the successful completion of the ILMA or AAM training programme, were examined.
Competence
Table 4 presents the three measures of competence used in this study, these being time on scene, overall success rate and the success rate on first attempt at tracheal intubation.
| Laryng oscope | ILMA | Difference | P-value | ||||
|---|---|---|---|---|---|---|---|
| Mean | (SD) | Mean | (SD) | Mean | (SD) | ||
| Confidence ( n =32) | 3.75 | (1.48) | 4.19 | (1.09) | 0.44 | (1.37) | 0.080 |
| Competence | |||||||
| – time on scene* | 33.7 | (14.99) | 28.9 | (10.63) | 4.80 | (13.10) | 0.140 |
| – overall success rate | 90% | (42/46) | 92% | (48/52) | 0.860 | ||
| – success at first attempt | 62% | (26/42) | 88% | (42/48) | 0.005 | ||
* Laryngoscope n=34, ILMA n=31
1. Confidence scores were from a Likert scale of 1-5, rating 1 being strongly disagree and 5 indicating strongly agree.
2. Time on scene is displayed in minutes and taken from the PILMAT trial data.
These results show that overall paramedics are more confident (mean 4.19) in tracheal intubation when using the ILMA than when using the laryngoscope (mean 3.75). Furthermore, paramedics using the ILMA reported shorter time on scene (28.9 minutes), higher success at first attempt (88 %) and overall success rate (92 %) than when using the laryngoscope, although not statistically significant. Because confidence and competence is so symbiotically linked with education it was important to carefully examine the educational components of the AAM training programmes that paramedics valued. For these reasons, confidence with ILMA and laryngoscopic tracheal intubation was compared across five areas, these being AAM training, pre-course theory; in-theatre training; guidance by an anaesthetist; manikin training, and CSO classroom training.
Education for competent and confident tracheal intubation
Table 5 summarises the level of confidence in tracheal intubation associated with each component of the AAM training process. The results show that paramedics value different educational approaches for the two different airway devices.
| Confidence in ILMA tracheal intubation | Confidence in laryngoscopic tracheal intubation | ||||
|---|---|---|---|---|---|
| Yes | p-value | Yes | p-value | ||
| Pre-course theory | yes | 96.4% (27/28) | 100.0% (22/22) | ||
| no | 3.6% (1/28) | .204 | 0.0% (0/22) | .019 | |
| In theatre training | yes | 64.3% (18/28) | 95.5% (21/22) | ||
| no | 35.7% (10/28) | .031 | 4.5% (1/22) | .749 | |
| Guidance by anaesthetist | yes | 46.4% (13/28) | 95.5% (21/22) | ||
| no | 53.6% (15/28) | .022 | 4.5% (1/22) | .022 | |
| Manikin training | yes | 100.0% (28/28) | 95.2% (20/21) | ||
| no | 0.0% (0/28) | .019 | 4.8% (1/21) | .869 | |
| CSO classroom training | yes | 100.0% (28/28) | .019 | 86.4% (19/22) | |
| no | 0.0% (0/28) | .019 | 13.6% (3/22) | 679 | |
1. There were 28 complete responses to the crosstab of ILMA tracheal intubation confidence and the training components and 22 complete responses to laryngoscope tracheal intubation confidence and the training components.
To develop confidence and competence in laryngoscopic tracheal intubation, paramedics consider in-theatre training (95.5 %) and guidance by anaesthetist (95.5 %) to be the most important educational components. Conversely, to develop confidence and competence in tracheal intubation using the ILMA, paramedics placed more value on learning with a manikin (100 %) and in-service training (100 %).
Frequent education and training was also identified as being important for AAM confidence and competence. During the interviews, paramedics indicated further practice within the immediate two or three months after the completion of the initial ILMA training would most likely further increase their levels of confidence. For instance, one paramedic stated;
‘Perhaps I would have liked to have had some sort of refresher, you know, you did your initial training, you go out, you use it for a month or two months whatever, then come back in and just go through it again.’
Overall 40 % of respondents reported that they would like to practice with laryngoscopic intubation every 1–8 weeks. Only 6.6% of respondents felt that frequency of practice sessions could be extended beyond six months. In comparison only 25.7 % of respondents wanted to practice the ILMA every 1–8 weeks with 40 % indicating that every 2–3 months was sufficient. The interview data also reflected the belief that frequency of practice with the ILMA could be less than for the laryngoscopic tracheal intubation while still maintaining confidence.
‘…with the ILMA I think you could go for an extended period and still feel reasonably confident.’
Willingness to use the ILMA
Paramedics recognised the ILMA as a necessary item for inclusion into their scope of practice and were aware they could achieve a similar tracheal intubation success rate as with the traditional laryngoscopic tracheal intubation. The majority of the participants in this study had experience in tracheal intubation which would make the inclusion of the ILMA as an alternative device easier as the context of the procedure is already well established.
For example the AAM qualified paramedics did indicate the ILMA provided a sense of reassurance for the situations when there was a difficult intubation and the potential of failure with the laryngoscope was increased
‘I still see a primary role in the more difficult intubations with an ILMA.’
But may be first choice in some circumstances:
‘I would go for the ILMA first because you have a better chance of getting it in, in the case of not being able to intubate via laryngoscopy I would obviously fall back onto that [ILMA]’.
Discussion
The unpredictable nature of paramedic practice means real world emergency situations often present new and complex cases that demand instant confident and competent interventions. Indeed, responding to people who require immediate emergency AAM in the out-of-hospital setting is one example of the unpredictable and complex nature of paramedic practice. Despite the high acuity of cases and demand of clinical competence, paramedic education and training as an autonomous professional venture is still in its infancy. Historically, training programmes in paramedicine were typically delivered as professional development sessions by employers and often involved blocks of theoretical instruction interspersed with supervised ‘on-thejob’ training (McCall, 2009). With tertiary entry level qualifications, the paramedic profession is now at an exciting stage in its development (Griffiths and Mooney, 2012). There is explicit recognition that to achieve the required level of responsibility and accountability for professional practice, paramedics need to be able to draw as strong evidence base to inform their practice. It was upon this premise this study sought to ascertain the key paramedic-reported factors that affect the implementation of the ILMA into paramedic practice with specific focus on educational practices.
The findings of this research are significant for paramedic education developers. The paramedics in this study reported confidence and competence in successfully performing tracheal intubation is difficult to maintain. The literature also shows tracheal intubation, particularly paediatric intubation, is infrequently required and a difficult skill to perform (Garza, Algren et al, 2004). The results of this study showing that paramedics are confident and competent in using ILMA device for tracheal intubation mirror other study findings. One study reported paramedic intubation success rates in unconscious patients was significantly higher (88 %) than laryngoscopic tracheal intubation (63 %) and that a 100 % intubation success rate was achieved for non-AAM qualified paramedics when using the ILMA (McCall et al, 2008). The results from this study show paramedics recognise the value of using ILMA for out of hospital airway care because of its usefulness in diverse patient care situations ranging from an intermediate airway device through to complete tracheal intubation in challenging emergency care situations. The results show paramedics are confident at their ability to insert the ILMA. They also regard themselves to be competent in AAM using this device measured by the high success rates on the first attempt of intubation, their overall success rates and reduced time spent at the scene. Although not seen as a replacement to the laryngoscope the ILMA offers an alternative to paramedics when a decreased confidence level in a skill such as laryngoscopic tracheal intubation exists. These are significant findings for paramedic practice because the inclusion of a new device which paramedics are confident and competent to use can positively influence their opinion and willingness to use it in practice. Evidence suggests easier tracheal intubation is associated with a wider acceptance of operator level and less complex training (Reardon and Martel 2001; Caponas 2002; Pandit et al, 2002; Tentillier et al, 2007).
While it seems intuitive that paramedic practices that lead to more successful AAM in out of hospital settings will lead to improved patient outcomes, more research is required in this regard. The study results show paramedics certainly consider AAM to be a crucial paramedic skill for optimally responding to emergency situations therefore it was important to give some consideration to education and training to prepare paramedics with the confidence and competence in AAM. Practitioner confidence has been found to be influenced by a diverse range of factors including complexity of the skill, frequency of practice (Vrotsos et al, 2008), clinical experience (Morgan et al. 2002) and the period immediately post training (Kovacs et al, 2000). The results of this study demonstrate that appropriate education and practice frequency affects confidence and is required to successfully implement the ILMA into paramedic practice. The study results show the paramedics in this study still value in-theatre AAM training to learn how to undertake laryngeal tracheal intubation. They also show that modes of paramedic education and training should reflect the specific AAM device and take into account the context in which it would be used in practice. If paramedics are reporting higher levels of confidence and competence in using the ILMA for out of hospital tracheal intubations, new approaches to their education and training should be considered. The value the paramedics in this study placed using manikins for learning about, and practicing, tracheal intubation insertion using the ILMA suggests new educational approaches such as simulated based learning could be usefully incorporated into paramedic education.
Conclusions
The current focus on the laryngoscopic method of tracheal intubation may be limiting performance and the safe practice of paramedic tracheal intubation. The success of introducing the ILMA as a suitable alternative for paramedic tracheal intubation is strongly influenced by the perceptions of confidence and competence and the nature of the related educational programme. Reported levels of competence and confidence in key elements of AAM including the ILMA are influenced by the types of education and training paramedics have experienced. The successful introduction of an innovation such as the ILMA into paramedic practice requires an education programme that is blended and establishes an effortless, supported and sustainable change to practice.
The results of this study support a shift in emphasis from in-theatre training to manikin– based training and in-servicing with opportunity to practice and receive timely feedback. Paramedic education developers can implement a blended approach to the initial training of AAM with the appropriate balance of teaching methods to support and sustain the appropriate levels of confidence and competence.