A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities

Abstract

Background: There is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult-not emergency-intubation. In this study, we describe and evaluate our equipment handling unit: the AIR-BOX.

Methods: This is a proof-of-concept, prospective, randomised simulation trial. A convenience sample of 50 airway course participants voluntarily underwent randomisation: 21 to the AIR-BOX group, 14 to the intubation box group, and 15 to the crash cart group. The volunteers were asked to intubate a manikin using the equipment from the storage unit of their randomisation. Outcome measures included time-to-readiness, time-to-intubation, first-pass success, and subjective operator experience.

Results: The mean time-to-readiness was 67.2 s with the AIR-BOX, 84.6 s with the intubation box, and 115 s with the crash cart. The mean time-to-intubation was 105 s with the AIR-BOX, 127 s with the intubation box and 167 s with the crash cart. A statistically significant difference was achieved between the AIR-BOX and the crash cart. No statistically significant difference was found between the three groups with regard to first-pass success or the time between intubation readiness and intubation.

Conclusions: This study supports the AIR-BOX as a viable tool that can improve and simplify access to emergency intubating equipment. It also opens doors for multiple future innovations that can positively impact equipment handling practices. Future studies can focus on assessing whether applying the AIR-BOX will yield a clinically significant impact on patient outcomes.

Keywords: Airway; Anaesthesia; Cognitive Load; Emergency Medicine; Equipment.

Figure 1

Illustrated here are the three storage modalities compared in this simulation study: the AIR-BOX we designed, the intubation box used in our ED and the crash cart used throughout our hospital. (A) The AIR-BOX: The case used for the AIR-BOX is a premade, commercial, travel bag chosen to fit our needs. The AIR-BOX is a concept—not a device— thus any similar product can be used. For reference: Universal Product Code: 733520405269; Amazon Standard Identification Number: B019BVLRKU. Folded size: 25 cm×16 cm×8 cm. Open size: 25 cm×72 cm. Price: $11.99 per unit. Total airway items: 11. For a complete list of items in the AIR-BOX, please refer to table 3 included in the Discussion. (B) The Intubation Box: The adult intubation boxes are maintained by our department’s material coordinators and restocked after every use. They are strategically located on top of every crash cart in the ED (as seen in C above), in the trauma and resuscitation rooms. Total airway items: 53. For a complete list of items in the intubation box, please refer to the table found in the online supplemental material. (C) The Crash Cart: The crash cart is the hospital standard and is located throughout the ED, inpatient units and other key patient-care locations. Quality control and maintenance are led by central supply, pharmacy and nursing departments. On the outside is a defibrillator, log binder, a bag-valve-mask for manual ventilation and an oxygen tank. The drawers contain (top-to-bottom) medications, vascular access equipment, central access equipment. Airway equipment is stored in the bottom drawer. Total airway items: 62. For a complete list of items in the crash cart, please refer to the table found in the online supplemental material.

Figure 2

Primary outcomes for the three randomization groups: mean time-to-readiness and mean time-to-intubation.

Figure 3

Results of the post-study survey given to the participants who were randomized to the AIR-BOX group. It included three open-ended questions aimed to assess the participants’ subjective experience while using the AIR-BOX.