Air ambulance clinicians working together with airway equipment arranged beside them

PAUL SWINTONPerformance by Design

Publications & research

Clinical performance is shaped long before the moment of crisis.

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What changes when we organise the work differently?

My work focuses on the design and development of systems that support human performance. SCRAM™ is one example: developed from aeromedical practice and now used by clinical teams in hospital and pre-hospital settings in the UK and internationally. Research is part of how I test design decisions and examine the organisation of clinical work. These studies sit within my wider work in human factors and systems design.

Alongside the studies, this page brings together examples of their use in later research and guidance, and accounts of SCRAM™ in clinical practice.

Alongside the papers are examples of how later authors have referenced or used the work. These are not exhaustive citation lists.

Evidence reviewed

Disclosure: Paul Swinton co-invented SCRAM™ with Neil Sinclair and has a commercial interest in the SCRAM™ system.

2018Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Preparing before the emergency

Randomised crossover simulation study

I led this study to examine what changes when airway equipment and drugs are prepared before they are needed. Clinical teams completed the same simulated emergency using conventional preparation and a combination of organised equipment and pre-prepared drugs.

Findings

  • Shorter procedural time
  • Fewer procedural errors
  • Lower self-reported cognitive load among assistants

Simulation comparing conventional preparation with equipment and drugs prepared in advance.

The findings relate to the combined preparation system; patient outcomes were not measured.

Study details

Teams completed the procedure more quickly with the prepared system. The median number of procedural errors per simulation was 0, compared with 9 using standard preparation. Mean self-reported cognitive load among assistants was 41.9 versus 68.7 mm on a 100 mm visual analogue scale. No statistically significant difference was detected for intubators. The study tested equipment and drug preparation together, with most of the time saving occurring during drug preparation.

Mean procedural time Combined equipment and drug preparation · simulation
Prepared system11 min 45 sec
Standard preparation20 min 59 sec

Reported means from the 2018 study. Most of the time saving occurred during drug preparation.

2020Perioperative Medicine

Equipment preparation outside the operating theatre

Randomised simulation study

This study examined whether the organisation of airway equipment could help anaesthetists prepare for an emergency away from the operating theatre. Fifty anaesthetists used either a standard resuscitation trolley or the SCRAM™ bag to prepare equipment for a simulated difficult airway. I helped design the study protocol and contributed to the paper.

Findings

  • Shorter equipment preparation time
  • Fewer preparation errors
  • Lower perceived task difficulty

Simulation comparing SCRAM™ with a standard resuscitation trolley.

The study measured equipment preparation and perceived difficulty, not patient outcomes.

Study details

Mean preparation time was 112 seconds with SCRAM™ and 157 seconds with the trolley. The median number of preparation errors per participant was 1 with SCRAM™ and 8 with the trolley; most were omissions. Mean self-rated task difficulty was 18.4 versus 50.6 mm on a 100 mm visual analogue scale. This measured perceived task difficulty, rather than cognitive load directly. Unlike the earlier study, this experiment examined equipment preparation alone.

Both airway studies examined performance in simulation. Neither measured patient outcomes.

2021Critical Care

Paediatric airway preparation

Conference abstract and presentation

This small crossover simulation study compared a standard resuscitation trolley with Paediatric SCRAM™. Twelve participants prepared equipment using both systems, with at least two weeks between sessions.

Reported findings

  • Shorter equipment preparation time
  • Fewer preparation errors
  • Lower self-reported workload

Paediatric SCRAM™ on first exposure compared with a standard resuscitation trolley.

Preliminary findings from a 12-participant simulation study, reported as a conference abstract.

Study details

The abstract reported an average 11.5% reduction in preparation time, 20% fewer errors and an average 9.8% reduction in self-reported workload with SCRAM™ on first exposure, without prior training. The accompanying presentation identifies the workload measure as the weighted NASA Task Load Index.

These findings come from a small simulation study, published as a conference abstract and accompanied by an oral presentation. The abstract does not report confidence intervals or significance tests for the error and workload differences. The study did not assess the effect of further training or familiarity.

Paediatric emergency airway preparation: standard practice and the SCRAM™ system. ISICEM 2021 oral presentation by M. Wylie, E. Waters, J. McCormack and P. Swinton.
Watch the presentation

In professional education

Cover of The Walls Manual of Emergency Airway Management, sixth edition

Sixth edition · 2022

The Walls Manual of Emergency Airway Management

The sixth edition of The Walls Manual of Emergency Airway Management features SCRAM™ in its discussion of system-level approaches to prehospital medication-facilitated airway management. The chapter identifies equipment organisation as one approach to improving operator efficiency and reducing risk, illustrated by SCRAM™ in use during simulated RSI in Figure 30.15.

Chapter 30 · Techniques in Prehospital Airway Management · Figure 30.15

View the book at the publisher

Use in clinical practice

Other clinical teams have used SCRAM™ within changes to equipment provision and training.

2023Royal Hospital for Children, Glasgow

Glasgow: organising equipment around the response

Quality-improvement report

Archives of Disease in Childhood – Education & Practice journal image

Jamie Pope, Jennifer Boyle and Mark Worrall used Lean/Six Sigma methods to review emergency airway management outside intensive care and theatres. Ward trolleys retained basic airway equipment, while PICU and anaesthetic teams brought advanced equipment in SCRAM™. The system was introduced across the hospital after consultation and trials in the emergency department and PICU.

The project linked equipment provision with the capabilities of the responding team. The authors reported equipment-cost savings and reduced waste, while identifying further training in basic airway management as essential.

This was a service improvement involving several concurrent changes. It did not demonstrate a reduction in adverse events.

Read the Glasgow quality-improvement report

2022NHS Highland

NHS Highland: preparing teams where they work

NHS programme account

Dora Paal and colleagues combined Paediatric SCRAM™ with locally developed checklists and action cards, supported by training delivered to rural teams in their own hospitals. The programme addressed emergencies that staff encounter infrequently, using their working environment as the setting for learning.

NHS Highland reported improved confidence and preparedness, with positive participant feedback.

These are reported experiences of the programme, rather than controlled evidence of improved patient outcomes.

Read NHS Highland’s programme account
View the poster
Programme posterPaediatric critical care in remote and rural settingsOutreach training and equipment preparationB. Martin · J. Dowell
D. Paal · J. WhitesideNHS Highland
Improving Paediatric Critical Care in a Remote and Rural Healthcare Setting: NHS Highland programme poster by B. Martin, J. Dowell, D. Paal and J. Whiteside
View the full poster

2018Injury

Clinician tasking in ambulance control

Retrospective before-and-after study

This work examined the identification of major trauma patients following the introduction of a trauma desk staffed by pre-hospital critical care clinicians in ambulance control.

Finding

  • Higher dispatch sensitivity for major trauma

Before-and-after comparison following the introduction of a clinician-staffed trauma desk.

An observational association; the study could not establish that the trauma desk alone caused the improvement.

Study details

We compared ambulance and trauma-registry data before and after the change. The sensitivity of dispatch for major trauma, defined as an Injury Severity Score above 15, increased from 11.3% to 25.9%. The findings supported clinician involvement in identifying patients and coordinating specialist care, although the observational design could not establish that the trauma desk alone caused the improvement.

AirMed&Rescue magazine cover

2021AirMed&Rescue

In conversation

Interview

I spoke to Mandy Langfield about the development of SCRAM™, the practical demands of retrieval work and the role of feedback from clinicians using the equipment.

Read the interview

Further reading

I also write about how ideas develop, how systems create difficulty and what it takes to support performance in practice.

Explore insights