iii. Hardwire Best/Critical Practices
1.     Utilization of a checklist/QA tool to hardwire and assess critical practices
2.     Airway assessment and planning
3.     Team communication and collaboration with plan/ performance
4.     Optimal 1 and 2 person Bag -Mask ventilation with appropriate oral and nasal pharyngeal airways
5.     Optimal patient positioning (e.g. Ear to Sternal Notch, Head Elevated Laryngoscopy Position (HELP),[1] RAMP for Obesity
6.     Apneic Oxygenation (“No DeSat”) for pre-oxygenation
7.     Prompt SGA use in failed VL/DL and primary placement in cardiac arrest codes
8.     Prompt emergency cricothyrotomy after VL, DL, SGA and BVM failure
9.     Waveform Capnography – Immediately and maintained on all intubations for continuous monitoring of ventilation and airway competency
10.   Use of non paralyzed or “Awake” techniques in appropriate clinical setting
11.   Use of flexible fiberoptic or video scope when converting SGA to endotracheal tube (ETT) and for Awake Fiberoptic Intubation (AFOI)
12.   Formalize system for appropriate sedation and patient restraints to decrease risk of unplanned extubation (UE)
13.   Formalize system for optimally securing ETT to avoid UE
14.   Implement best practice guidelines for weaning & planned extubation
15.   Implement system for recording and alerting clinicians (similar to allergies) for patients with known difficult airways (DA)
16.   Utilize a robust system for tracking and analyzing QA, adverse, and near miss events for airway management (airway registry beyond hospital safety reporting system) for all difficult and failed airways and unplanned extubations
                                   iv. Team Training
1.     Implement a system where all physicians and staff receive initial and recurring team based training for protocol, equipment and critical practices, as well as utilization of critical clinical and teamwork best practices.
2.     Ensure all intubating clinicians are appropriately trained and credentialed.
[1] Levitan, R. M., Mechem, C. C., Ochroch, E. A., Shofer, F. S., & Hollander, J. E. (2003). Head-elevated laryngoscopy position: Improving laryngeal exposure during laryngoscopy by increasing head elevation. Annals of Emergency Medicine, 41(3), 322-330.