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Standardising Pre-Hospital Rapid Sequence Induction: Introduction, Implementation, Outcomes?

Adam Pritchard / Steven Margolis
Rfds, Edge Hill, Australia, Griffith University, Brisbane, Australia



Dr Adam Pritchard (FACRRM, JCCA, DCH, PGCert Aeromed) is an Aeromedical Retrieval Specialist with the Royal Flying Doctor Service based in Cairns and Mt Isa.  He is a Fellow of the Australian College of Rural and Remote Medicine, with an advanced skill in Anaesthetics.  He has worked in aeromedical retrieval, in both fixed wing and rotary wing operations since 2007.  He also works in remote general practice.


Rapid Sequence Induction in the pre-hospital environment poses significant risks to critically unwell or injured patients. The challenges include (1) the inherent risk of sedation and paralysis; (2) the physical environment including, access and patient positioning; (3) limited resources especially medication and equipment and; (4) crew resource issues including communication, planning and decision making.

Evidence from the aviation and military literature suggests that the use of a standardised approach with checklists to structure complex tasks decreases errors and omissions. The application of this approach to RSI in prehospital medicine seems logical.

Correspondingly, the RFDS, Queensland Section, introduced a Standard Operating Procedure (SOP) for Prehospital Rapid Sequence Induction (RSI), in June 2015. This included a standardised approach to technical aspects including pre-oxygenation, medication selection and equipment utilisation, plus enforced non-technical aspects through preparation, organization and communication.  Implementation involved formal training workshops and the requirement for clinical teams to train in RSI, during their routine workday.

Eighteen months later, as part of a routine quality assurance activity, the RFDS surveyed the clinical staff (medical and nursing) to examine changes relating to training, perception, performance and other aspects of the SOP.

The results demonstrate statistically significant improvements in organisation, readiness, communication and difficult airway planning.  Anxiety levels decreased.  Confidence in the equipment, drug selection and other members of the team all increased.  Overall confidence in the procedure increased.  The current SOP, along with daily training has been widely accepted by clinical staff.

This paper will present evidence that the introduction of a SOP for RSI in the prehospital setting was well received and found to be helpful. The paper will also discuss the components of the RFDS SOP and the implementation process used by RFDS.  This paper will be helpful for those considering introduction or evaluation of an SOP in this setting.


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