Rhode Island Department of Health
Three Capitol Hill
Providence, RI 02908-5097
www.health.ri.gov

Memo
Advisory from the Center for Emergency Medical Services (CEMS),
Division of Preparedness, Response, Infectious Disease and EMS
#2019.03
To:

EMS Service Chiefs, EMS Coordinators, EMS Medical Directors, EMS Training Officers

From: Nicole Alexander-Scott, MD, MPH; Director of Health
Jason M. Rhodes, Chief; Center for Emergency Medical Services (CEMS)

Date: April 30, 2019
Subject: Updated recommendations for orotracheal intubation

This advisory is being issued by after a recent cardiac arrest case transported by a Rhode Island-licensed
ambulance service to a hospital emergency department with an unrecognized intubation tube that was in
the esophagus and not the trachea, resulting in death. We are aware that 11 such events have occurred in
the last 3 years. In addition, the mandated waveform capnography monitoring was not performed and
nor was a tracing recorded in the electronic patient care report. This is an unacceptable high rate of
esophageal intubation. To best protect patient safety, we strongly recommend the following procedures be
adopted by all EMS practitioners.
•

BIADs are airway of choice in all cardiac arrest patients
Supraglottic blind insertion airway devices (BIADs), e.g. i-Gel®, King® laryngotracheal tube,
and laryngeal mask airway will be the advanced airway products of choice in all cardiac arrest
victims for all EMS practitioners. Orotracheal intubation will only be indicated for use in patients
where BIADs are insufficient to facilitate adequate ventilation. Studies indicate that orotracheal
intubation offers no appreciable improvement in patient outcome when a BIAD is providing

 adequate ventilation. Also, the interruption in delivery of compressions while an orotracheal
intubation attempt is made may be harmful. Continuous waveform capnography that confirms
advanced airway placement is mandatory and must be monitored.
•

Documentation of airway procedures required in ePCR
All advanced airway management, including BIAD insertion, intubation, and intubation attempts
made by EMS practitioners must be documented thoroughly in both the narrative and drop-down
procedure section of the electronic patient care report (ePCR). Additionally, evidence of
continuous waveform capnography that confirms advanced airway placement must be
documented in the ePCR. The waveforms must be uploaded into the ePCR. This is a standard of
practice that applies to advanced airways inserted by all EMS practitioners and for transfer of
interfacility patients with advanced airways already in place. EMTs must use frequently
documented colorimetric CO2 detection, and all other EMS practitioners must use continuous
waveform capnography and upload it to the ePCR. The name of the physician who accepts a
patient with an advanced airway must be documented in the ePCR narrative section. According to
the Rhode Island Statewide EMS Protocols, an intubation attempt is defined as the introduction of
a laryngoscope blade, endotracheal tube, or BIAD beyond the patient’s lips or the insertion of an
endotracheal tube into the patient’s nasal passage. Every effort should be made to minimize
interruptions in chest compressions during airway management and to maintain adequate
oxygenation during intubation.

•

Review of airway management by Medical Director and EMS Coordinator required
All advanced airway management, including BIAD insertion, intubation, and intubation attempts
made by EMS practitioners must be reviewed by the service’s Medical Director and EMS
Coordinator. The Center for Emergency Medical Services (CEMS) is creating a continuous
quality improvement (CQI) module in ImageTrend to help facilitate this process and provide
CEMS with a mechanism for assuring these reviews are taking place. An instructional document
and rollout will be developed, for use by EMS Medical Directors and EMS Coordinators, to help
facilitate these reviews.

Resource / reference: National EMS Scope of Practice Model 2019
Contact CEMS Training Coordinator Eric D Rossmeisl by email at eric.rossmeisl@health.ri.gov or by
phone at (401) 222-5658 with any questions that may arise regarding documentation or review of
intubations by EMS providers.