BARRIERS TO ADOPTION OF EVIDENCE-BASED PREHOSPITAL AIRWAY MANAGEMENT PRACTICES IN CALIFORNIA

Objective. To describe current prehospital airway management practices for adults and children and barriers to adoption of evidence-based airway management practices in California. Methods. We surveyed local medical directors of California's 31 emergency medical services (EMS) agencies regarding prehospital airway management, including provider scope of practice, continuous quality improvement practices, and perceptions regarding barriers to the implementation of evidence-based airway management practices. The survey instrument was a Web-based, closed-response form (www.surveymonkey.com) that medical directors could access by an e-mailed link provided by investigators. Medical directors were contacted by phone, mail, and e-mail to request their participation in the Web-based survey. Results. Twenty-five of 31 (81%) EMS medical directors completed the survey. Five medical directors completed surveys for two agencies over which they had responsibility. All responding medical directors employ bag-mask ventilation (BMV), airway adjuncts, and adult endotracheal intubation (ETI), which are procedures widely accepted in EMS practice. Rapid-sequence intubation (RSI), which has been shown to cause harm in certain patient subgroups, was not employed by any of the respondents. Prehospital pediatric ETI, which has been shown not to provide any benefit over BMV, was employed by 22 of 25 (88%) medical directors. Thirteen of 23 (57%) respondents identified more evidence is needed or these results do not apply to my EMS system as the top reasons to continue the practice of prehospital pediatric ETI. Conclusions. The results of our study suggest that in areas of EMS where robust evidence exists, medical directors (100%) will discontinue or not adopt skills that potentially harm patients, such as RSI, but are unlikely (12%) to discontinue procedures that show no benefit to patients (such as pediatric ETI). Barriers to adoption of evidence-based practice include difficulty in generalizing results of studies across diverse EMS systems and perceived lack of evidence that the procedure should be abandoned.