Complying with ACS Standard 5.11 for Emergency Airway Management

Authored by:  

Bill Briggs, MSN, RN, CEN, TCRN, NEA-BC, FAEN
Vice President and Managing Partner

Providing a definitive airway is a routine procedure in operating rooms, emergency departments, and ICUs, however, providing the same airway in the presence of trauma is fraught with obstacles. First, there is little time to plan and set up for the procedure. Second, there are many anatomical abnormalities including spinal cord damage, neck edema or an expanding hematoma obstructing the airway, damage to the breathing mechanism such as tracheobronchial injury, ruptured diaphragm, flail chest, or pneumo-hemothorax. In addition, the airway may contain blood, secretions, and vomit. All these scenarios can make it difficult to visualize the usual landmarks for intubation and may obstruct the passing of an endotracheal tube.

Emergency Airway Management
In the 2022 edition of Resources for Optimal Care of the Injured Patient, the American College of Surgeons (ACS) added a new standard, 5.11 Emergency Airway Management which states:

“All trauma centers must have a provider and equipment to immediately available to establish an emergency airway.”

The standard goes on to say, “emergency airway provider must be capable of advanced airway techniques, including surgical airways.” To measure your compliance with the standard the ACS reviewers will “verify that the plan specifies the provider and means of escalation.” They will also review the equipment during the visit. This standard is categorized as a Type I and non-compliance will prevent your trauma center from being verified. The ACS requires that you submit your plan in the prereview questionnaire (PRQ).

This article is not meant to be a definitive source for airway management, but instead to provide you with some guidelines to develop a customized plan for your facility. A definitive airway is generally defined as a method that maintains a secure open airway, allows for mechanical ventilation, and prevents aspiration such as an endotracheal intubation or a surgical airway (cricothyrotomy or tracheostomy).

1. Formulate your plan
The plan must be specific to your organization and include who, what, where, and when of providing an emergency airway. The plan will be very different in a major teaching hospital with vast resources and a rural hospital with one provider in the ED.

There are numerous examples of trauma emergency airway plans available, but you must customize your plan to match your staffing, your equipment, and your policies, guidelines, and protocols. This plan must be inclusive of a location in your trauma center where a trauma patient may require emergency airway management.

2. Organize your equipment, medications, and supplies
In trauma situations, there is no time to search for airway equipment. All necessary supplies should be stored together – preferably in a cart or box located in or adjacent to the trauma room. This will allow the equipment to be moved to another location if necessary. Equipment should be checked regularly for both availability and function. You can save time by having the equipment secured with breakaway locks. A staff member must be accountable to check the equipment at least daily and after every use. A log of the checks should be maintained and available for the surveyor.

    It is important to remember that every trauma center must be able to provide stabilization for the injured child (ACS Standard 5.10), so make sure you have all the appropriate pediatric sizes of equipment.

    The drugs needed for intubation may be secured in a drug dispenser system in the trauma bay or nearby. The hospital Pharmacy can assist you in developing a standardized rapid sequence intubation (RSI) kit that will allow you to pull all the medications you need at once.

    3. Know your people resources
    Within your hospital you must know who is credentialed to provide an emergency airway. Depending on your hospital policies, this may include emergency physician, trauma surgeon, anesthesiologist, Certified Registered Nurse Anesthetists (CRNA), intensivist, advanced practice provider (APP), respiratory therapist, or paramedic. Additionally, at least one provider must be capable of performing a surgical airway. Your emergency airway plan should clearly list these individuals and outline the process for mobilizing them to the trauma bay or other critical care areas.

      If you have any indication that you are dealing with a difficult airway, you should have your backup providers at the bedside before the procedure begins – do not wait until their assistance is urgently needed. One best practice is to have difficult airway alert that notifies the appropriate staff is notified, such as a “Code Airway” page.

      4. Escalate your plan at the first sign of trouble
      One of the key components of the plan must be how you escalate the situation when something is not working as predicted. This could include a different method of securing the airway or a different provider taking over. This might mean an attending or an anesthesiologist taking over from a resident. It may also require modifying the approach, such as transitioning to a fiberoptic bronchoscope or temporarily managing the airway with a supraglottic airway. Occasionally, establishing a surgical airway may become necessary.

        The plan allows all members of the team to be on the same page. For every airway emergency there should be a plan and a backup plan that the team is aware of. When time allows, this can be discussed before proceeding with emergency airway management procedures.

        5. Train and rehearse the plan
        No emergency procedure is of any use if it is in a manual or online and only dusted off when you are expecting a visit by an accrediting body. All team members must be familiar with the contents of the plan and their individual roles during an airway emergency.

          Consider having job aids available such posters in the trauma bays. Training should be performed regularly and hands-on, so team members will remember their responsibilities. Doing periodic simulations of a trauma airway is one of the best ways of being prepared. Be sure to include all members of the trauma or emergency team including providers, nursing staff, respiratory therapists, and pharmacists. Make the situation as realistic as possible, including some adverse events such as a failed airway, or a missing piece of equipment. Also ensure that all shifts are included.

          After any simulation or real event, have a short debriefing including what went right, what could have been done better, and what actions will be taken to improve the plan.

          Conclusion
          An emergency airway management plan is essential to safe trauma care and to a successful ACS trauma center verification. It is not sufficient to adopt a generic or templated plan; your airway management plan must be tailored to your facility’s specific capabilities and available resources. Be prepared to discuss your plan and how it works in your trauma center. During a site visit, ACS reviewers may ask staff about the plan and expect to see a demonstration of the airway equipment.

          All emergency airway equipment should be centrally located, immediately accessible, in good working order, and routinely checked for readiness.

          A well written and rehearsed emergency airway plan enhances the quality of care for all patients requiring emergent airway support – not just trauma patients.