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I have had the privilege to participate in many airway management performance improvement, quality assurance/quality improvement projects over the last couple of decades. I am never shocked by the presence of two things:
- Opinion masquerading as evidence.
- Assumptions dressed up as facts.
This leads to a plethora of weaknesses in the QA process: bias, subjectivity, and an overwhelming focus on the outcome, to name a few. Trying to move the needle on an entire organization’s performance in intubation, with these weaknesses baked into the QA process, follows a rather predictable pattern.
The group will likely see an initial improvement in the metric they are looking at, but then it will plateau, and that plateau will likely still be short of their target. Follow this with a dramatic overcorrection in the policies and procedures in an attempt to force the desired outcome instead of engineering it, and the hole in their process only becomes more apparent.
The robotic adherence to the policies and procedures during training will result in a frustrating expectation for metric improvement, but it may or may not move.
This is the problem with outcome-based QA versus performance-based QA. Perhaps a grittier take on it would be: you can be good, or you can be lucky.
Outcome-Based QA
Overall successful intubations, first-pass success intubations, X amount of time to tube placement, and medication dosages correct for rapid sequence intubation (RSI) are examples of outcome metrics. As are if the team is successful a certain percentage of the time, or passes the tube on the first try X percentage of the time.
While they are not to be ignored, they do not evaluate how safely or how dangerously the procedure was performed. How much risk was the patient exposed to (hypoxia, hypotension, etc.)? Were the risks addressed before induction and the intubation attempt?
Performance-Based QA
How safely was it performed? If there was a miss or a failed attempt, were X, Y, and Z protocols followed?
Was the outcome going to be the outcome regardless of the process followed, or was the outcome what it was because there was no process? Performance is not about securing the airway with an ET tube; it is about how well the procedure was executed.
Airway QA in 2026
I would argue that unless you are evaluating the process to getting first-pass success (or an overall successful intubation), then you have a massive blind spot in the QA process. That blind spot will lead to an even bigger blind spot in your training program. Month after month, you will find that the metrics are not moving as well as you would like.
Our ability to review intubations, prehospital intubations at that, is unparalleled in 2026. In the “olden days,” the best we could do was review the charts of the field clinician to get an idea of how well or poorly the procedure went in the field.
All we had to go on was the documented outcome, generally. It is very difficult to build high-quality, data-driven quality assurance with sparse or incomplete information (measured against what we have access to today).
Today, we have access to more than charting and vitals. We can review the data of the cases in variables of seconds or minutes and see in real time the instant a patient desaturates, stops breathing, and becomes hypotensive.
We merely need to upload it to our cloud software and download it to our computers, and then we can match the narrative to the data. This is the functional equivalent to being able to watch pro sports game tape.
Even more useful is the ability to review the videos from the operator’s video laryngoscope. We get to see what they saw, instead of speculating what happened, with the goal of accurately collecting and synthesizing data to support and improve the performance of our clinicians in the field.
Data is how we tease apart the good from the lucky.
From Good Enough to Better
It is not enough to simply be able to watch the video of an intubation and react to what you see on the screen. You need performance standards and a process to measure them by. A rubric.
Without a specific rubric to follow, we may miss the information and instead fall back on an opinionated John Madden-style “play-by-play” analysis of the procedure. This approach may fall flat with your clinicians. This places the evaluator in a position as the “all-seeing, all-knowing, QA god” instead of a teammate working to improve their team’s performance.
Jiang et al, Sackles et al, and Weingart et al provide just the sort of rubrics we need to accurately and fairly evaluate intubation performance via video laryngoscopy (VL). But you can take this further.
Have the clinicians watch their videos and evaluate them according to the same rubric. Afterward, you two can compare notes and evaluations, almost how a pro athlete evaluates their game tape and then meets with the trainers to figure out how to improve the weaknesses and hone their edge.
Redefining Success
Being better starts with identifying the largest contributors to VL success or failure:1-3
- contaminate the oropharynx/airway (suction-assisted laryngoscopy and airway decontamination)
- midline approach
- tongue controlled
- blade in the vallecula
- tube was introduced past the cords
Minor Themes:1-3
- tube in the view before the cords are visualized
- vallecula not fully engaged
- “Millering” the VL (blade is under the epiglottis)
- blade introduced too deep into the oropharynx
The presence of these elements does not always lead to a failed attempt; that is important to note. Often, I have seen clinicians still successfully manage to correctly place an ET tube in the presence of one or several of these elements. It is just as important to address success with bad technique as it is to address the elements that lead to a failed attempt.
For the QA program to reach maximum effectiveness, it must inform the follow-on training for the line clinicians. The instructors best serve their teams when they can help their teammates overcome these errors.
Some VL devices allow for casting the camera to a TV screen. This is an invaluable tool for an instructor. Being able to show the group what an error looks like and then how to overcome it or defeat encountered difficulty is priceless to your training and QA program.
Conclusion
Data is our greatest tool in the building and maintenance of our airway management QA and training programs. The video data provides us the best chance of understanding the procedural errors that lead to failed attempts, while the physiologic data from our monitors provides us with the answers to “how safe” it was to attempt intubation or RSI.
Putting these data elements together with the clinician narrative gives us the best information for QA, almost as if we were standing right there and watching the procedure ourselves.
But beware of the trap. The data, the video, and the narrative do not provide us with context. It does not give us an inkling of understanding of what the individual clinician was going through.
We cannot feel their pressures, hear their thoughts, or understand the level of self-doubt they may be struggling with during the procedure. We cannot forget about the human on the other end of the camera.
References
1. Jiang AA, Wardi G, Sweeney DA. Video-recorded Endotracheal Intubations: An Educational Tool in Airway Management Training for Pulmonary and Critical Care Fellows. ATS Sch. 2024 May 31;5(3):442-450. doi: 10.34197/ats-scholar.2023-0125IN. PMID: 39371239; PMCID: PMC11448834.
2. Weingart SD, Barnicle RN, Janke A, et al. A taxonomy of key performance errors for emergency intubation. The American Journal of Emergency Medicine. 2023;73:137-144. doi:10.1016/j.ajem.2023.08.035
3. Sakles JC, Mosier J, Patanwala AE, Dicken J. Learning curves for direct laryngoscopy and GlideScope® video laryngoscopy in an emergency medicine residency. West J Emerg Med. 2014 Nov;15(7):930-7. doi: 10.5811/westjem.2014.9.23691. Epub 2014 Oct 29. PMID: 25493156; PMCID: PMC4251257.
Cody Winniford is a flight paramedic and base manager in Baltimore, MD. He has a passion for sharing his professional experience in EMS and management. Cody’s clinical and leadership development background spans both military and civilian settings and has served in several capacities as a leader and prehospital clinician. He specializes in air medical and critical care transport, as well as organizational development and leadership development. He is an active speaker on various leadership and clinical topics and is an established and successful educator for prehospital clinicians of all levels. He has a passion for human performance improvement and the mental health and performance aspects of prehospital care.
