For decades, rapid sequence intubation (RSI) has been the most-used intervention for select respiratory care, especially in acute and critical prehospital settings. But Randy Budd, RRT, CEP, EMS captain for the Mesa Fire and Medical Department in Arizona, and a registered respiratory therapist and certified emergency paramedic, wants to change that.
Budd was involved in the early implementation of RSI protocols for Mesa Fire and Medical more than 10 years ago. “I felt it was inhumane to intubate people who were somewhat conscious, without giving them medication and having intubation be a more sequential process,” he said. He also thought the prevention of intubations could be equally as valuable for patients. “Intubation can cause infection, and it doesn’t go without risks. I thought there might be other ways to provide ventilation without putting an endotracheal tube in their trachea.”
Budd wanted prehospital providers to have the knowledge and training to provide patients in the field the opportunity to be ventilated noninvasively. The more he thought about it, the more he knew that using noninvasive positive pressure ventilation (NPPV), specifically bi-level ventilation, was something providers could learn to execute successfully.
With years of training as a respiratory therapist in both hospital and air transport environments, and with a gifted passion for teaching, Budd set out to introduce the use of NPPV in the prehospital setting as a mainstay in field care. To implement this change in culture would require a detailed training program and the right technology to train EMTs and paramedics. Budd started with evaluating ventilators that would work effectively and also stand up to the rigors of the prehospital setting.
“We had to select the right piece of equipment,” Budd said. “Technology has been advancing and there is equipment out there that’s being used in the hospital and the air medical industry that is capable of doing noninvasive positive pressure ventilation.”
Since he had extensive experience in prehospital ventilation from his years as a flight respiratory therapist, Budd evaluated 10 different ventilator devices. “I looked at how much they weighed, their capabilities, easeof- use and consumption of oxygen,” he said. “We had to select the right device, one that would do what we wanted it to do and serve its function long after we purchased it, so it wouldn’t become obsolete the day we put it on our apparatuses. I spent months figuring that out.”
When he settled on the right device, Budd made a recommendation to Gary Smith, MD, Mesa’s medical director, and to the purchasing department at the city of Mesa. Budd then developed a training program for a group of “master trainers”: EMTs and paramedics who would learn the new skills and take them back to their agencies and stations. The first step in the training was to teach the group new ways of looking at the pathophysiology of the respiratory system, which Budd realized was training they didn’t receive in paramedic school.
“We bought lamb lungs and let the group dissect them. Then we showed them different functions of the ventilator and how it worked on the animal model,” Budd said. “The use of lamb lungs was beneficial to the members because we talked about noninvasive ventilation and lung protective strategies.
The providers didn’t understand that because they didn’t get it in paramedic school, but they needed it for this program to be successful.”
Once the group had been properly trained, they were sent to their stations to teach the bi-level NPPV to crews on every shift. Not only did the providers get to learn in a familiar setting with their own equipment, but they also practiced as a crew in assessing and treating a patient using bi-level NPPV.
All providers were also run through ventilator-related scenarios they dealt with daily in the field. They were taught how to adapt to and overcome extraordinary kinds of critical respiratory situations while caring for patients.
In addition to the training program, Budd worked closely with Smith in developing new offline protocols using bi-level NPPV for patients with congestive heart failure, chronic obstructive pulmonary disease and other respiratory illnesses.
Budd admits he had some pushback from people who weren’t convinced such a training program could be successful and that the notion of providing NPPV in a prehospital setting was best left to medical experts at the hospital who are specifically trained in that process.
“I didn’t agree,” said Budd. “Some people thought the program was going to be successful and some didn’t. But some colleagues out of the hospital, including Budd’s medical director, trusted him enough to try to implement the program. “There’s always going to be naysayers, but sometimes you have to step out of the box and see if it works or not,” he said.
The results speak for themselves. From April through October 2014, bi-level NPPV has been successfully used on 107 people. Eighty-four patients avoided in-hospital intubations, 56 avoided prehospital intubations, and seven were discharged from the ED without hospital admission.
“The majority of patients went to telemetry, with a 4:1 or 6:1 nurse to patient ratio, and they had shorter stays than those who were intubated and went to the ICU,” Budd said. “This means their risk for developing an in-hospital infection, such as pneumonia or clostridium difficile, decreased dramatically.”
Perhaps most significantly, after receiving the training, providers are reporting that they find bi-level NPPV easy to use, easy to apply, and highly effective in relieving respiratory distress in their patients.
One of the key steps that were taken with this project was the involvement of regional hospitals, which allows the Mesa Fire and Medical Department to track outcomes and determine the successes of noninvasive ventilation. “Since we’ve rolled this out in April 2014, we’ve had more than 84 patients who we’ve prevented from having in-hospital intubations, in just that short period of time,” Budd said. “I don’t even know how we would measure that in healthcare savings, but it’s huge.”
Budd wants to make clear that the Mesa Fire and Medical Department still provides intubations when necessary for its prehospital patients, but since implementing the training, the number of those intubations has, and continues, to decrease significantly for the citizens of its community.
Bi-level NPPV is currently used by the Mesa Fire and Medical Department and isn’t part of the Arizona EMS’ Regional EMS Directory. An article outlining the procedure is detailed in the July 2014 JEMS issue, called “Stuck in a Trailer: Noninvasive positive pressure ventilation is intubation alternative.” A follow-up article appears in the November issue.
Eventually, Budd would like to see EMTs and paramedics around the country, and around the world, trained in providing NPPV. “The impact this has had on our community on a daily basis is amazing,” Budd said. “I think it needs to go regionally and nationally.”
When Budd started on the journey of making this training successful, he was designated full time on the department’s fire truck. But as the program grew in complexity and success, he realized that it needed his full-time devotion. “I needed to get closer to managing it, so I took a step off the fire truck and took a position in the EMS division as an EMS captain, which is a position I had done years ago,” Budd said. “I needed to make sure this program was managed successfully.”
In addition to overseeing the training of hundreds of paramedics, Budd has developed formal partnerships with the local hospitals and follows up with their paramedic coordinators on every patient who receives the NPPV modality. He wants information on patient outcomes as they relate to intubation.
“Did we prevent them from getting intubated during their stay at the hospital? Did they need to go to the critical care unit or did their outcome improve because of this being implemented?” he said. “And how many dollars have we saved the healthcare community by not intubating a large number of these patients who in the past would have received intubation?”
Developing and launching the NPPV program has not been easy, but it’s been worthwhile for Budd and the department. “I didn’t realize the sacrifices I would have to make for my family to run such an intense program,” he said. “But when I teach 450 members a new way of doing something, instead of touching one patient, I am touching thousands of patients. The reward of that is immeasurable.”
