Effect of Suction Assisted Laryngoscopy Airway Decontamination (SALAD) Training on Intubation Quality Metrics

VCU Health Critical Care Transport Network paramedics and nurses staff three rotary-wing aircraft and one ground ambulance that provide scene response and interfacility transports throughout Virginia. Prehospital rapid sequence induction and intubation are among the highest risk procedures employed by these providers, particularly when the airway is massively contaminated with blood or vomit. A quality assurance review of attempted prehospital intubations determined issues with suction to be a key factor in those requiring more than one attempt. A targeted training session introducing Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) was implemented and quality improvement data collected.

SALAD was introduced during scheduled quarterly training. In attendance were 15 nurses and 10 paramedics for a total of 25 participants. With no prior notice, training or cognitive priming each participant attempted intubation using videolaryngoscopy on a custom high fidelity training mannequin designed to emit 650 ml per minute of simulated vomit into the airway. Following their first attempt, participants were instructed on SALAD technique by an EMS-fellowship trained emergency physician. Participants then had another opportunity to intubate the mannequin using SALAD technique. Data was collected on number of attempts and time to successful intubation before and after training.

Mean time to successful intubation improved from 68.28 seconds to 49.76 seconds (95% confidence interval [CI], -34.976 to -2.064; P = 0.0282). There was a trend toward improvement in mean number of intubation attempts overall from 1.12 per participant to 1.0 (CI, -0.0135 to 0.2535; P = <0.0001). Subgroup analysis, however, found there to be significant improvement for participants whose first attempt time was greater than 91 seconds, from a mean of 127.40 seconds to 53.80 seconds (CI, -116.674 to -30.526; P = 0.043) and 1.6 attempts per participant to 1.0 (CI, -1.165 to -0.0349; P = 0.0400) post intervention.

In a controlled environment, SALAD training improves both first pass success and total time to successful intubation. The greatest improvement was observed in the group with the most difficulty and longest time to intubation prior to the targeted educational intervention. This indicates that the introduction of an effective, standardized suction technique for massively contaminated airways can significantly improve quality metrics for intubation by prehospital providers. Further research is needed to determine skill retention and generalizability to an uncontrolled environment.