Structured CRitical Airway Management
The SCRAM™ Story
A structured, reproducible approach to emergency airway preparation — designed to reduce procedural time, error rate and cognitive load.
Read the originWhy SCRAM™ exists
It began with a preparation problem.
SCRAM™ came from a simple observation: even well-practised methods of preparing for emergency anaesthesia can become vulnerable when exposed to the realities of pre-hospital care.
Emergency anaesthesia with oral tracheal intubation is used to manage critically ill or injured patients who cannot maintain their own airway or achieve adequate ventilation.1,2
When emergency airway management takes place outside the operating theatre, the risks increase. Poor planning, absent or unfamiliar equipment and interrupted workflow can all contribute to harm.3,4,5
Preparing for emergency anaesthesia involves establishing an equipment kit dump and preparing the drugs required for the intervention. One well-described method is to lay equipment out on a clinical waste bag.
That method can be familiar, practised and useful. The issue is not the team, the training or the recognised layout. It is that the preparation still has to survive the scene: wind, weather, limited space, clutter, movement and pressure.
Equipment laid out on a clinical waste bag.
A recognised and familiar method for creating an airway kit dump at the scene.
Equipment arranged on a structured preparation sheet.
A more organised setup, but still one that must be created and protected in the environment.
The problem before the product
The method worked. The environment exposed it.
A kit dump gives the team a working layout. In pre-hospital care, that layout has to hold up in conditions the team does not control.
Equipment is laid out for the intervention.
Airway equipment and drugs are prepared using a known structure for emergency anaesthesia and tracheal intubation.
The scene adds pressure.
Movement, restricted space, adverse conditions and time pressure expose preparation at the point it is most needed.
The value had to be clinical.
SCRAM™ was built to redesign the preparation phase itself — the point where the conditions of the whole procedure are set.
The design question
The real question was not how to carry equipment.
Not simply: how do we carry airway equipment?
Can preparation itself be designed to reduce procedural time, error rate and cognitive load?
Using the principle of marginal gains, emergency anaesthesia and tracheal intubation were broken down into their core components.10
The aim was not to improve everything at once. It was to identify where the most meaningful clinical gains could be made.
The preparation stage stood out. It was early enough to influence the whole intervention, practical enough to redesign, and important enough to affect safety, flow and team workload.
The decision followed: design preparation as a clinical intervention in its own right — something that shaped the procedure, not simply readied it.
Process improvement through design
The gain is not the 1%. It is knowing which 1% changes the work.
Small changes. Different conditions.
Not every change matters equally.
The value comes from improving the right parts of preparation. As those changes accumulate, they alter the conditions of the procedure — reducing procedural time, errors and cognitive load.
The design move was to build that preparation work into the system, rather than recreate it under pressure.
Clinically meaningful change
Procedural time
reducedErrors
reducedCognitive load
reducedPreparation is not the thing done before the procedure. In an emergency airway, it is part of the procedure.
Evidence
Preparation changes performance.
When the SCRAM™ approach was evaluated in peer-reviewed research, the effect was practical: shorter procedural and kit-preparation time, fewer errors, and lower cognitive load.
Pre-preparation changed the conditions of the procedure.
A randomised crossover simulation study examined pre-prepared equipment and drugs for pre-hospital emergency anaesthesia. Compared with standard practice, the experimental method reduced procedural time, reduced procedural errors and reduced the cognitive load experienced by the intubator assistant.1
The important finding was not simply that the procedure became faster. The preparation system changed the work: less time spent setting up, fewer errors during preparation and delivery, and less cognitive burden placed on the assistant at a high-pressure point in care.
Design signal: Preparation is not background work. It is a fundamental part of clinical performance.
The SCRAM bag changed remote-site kit-dump performance.
In a simulated remote-site difficult-airway scenario, use of the SCRAM bag was associated with quicker kit-dump completion, fewer errors and lower perceived difficulty when compared with a standard resuscitation trolley.5
Evidence signal: The finding was not that outcomes were proved. It was that preparation changed the conditions of performance.
The design problem translated into paediatric systems.
Paediatric simulation work reported shorter kit-dump completion time, fewer errors and reduced cognitive load. Later paediatric quality-improvement work moved from simulation into implementation, reporting more standardised preparation, reduced equipment waste and a local cost-saving signal.6,7
SCRAM™ as the mechanism
The system has to do more of the work.
SCRAM™ — Structured CRitical Airway Management — was co-invented and developed by Paul Swinton and Neil Sinclair to improve the preparation and delivery of emergency anaesthesia and tracheal intubation.
In high-pressure clinical environments, clinicians are not short of knowledge. They are often short of time, space, certainty and spare cognitive bandwidth.
The more a clinician has to search, select, interpret and reorganise under pressure, the more avoidable cognitive load enters the system.
SCRAM™ organises equipment around the sequence of the intervention: a structured, reproducible kit dump that makes essential components visible, reduces unnecessary searching and reorganisation, and gives the team a shared reference point before the procedure begins.
Why SCRAM™ is different
A preparation system, not just a bag.
SCRAM™ is a structured, reproducible approach to airway management, standardising and organising equipment — and, where appropriate, drugs — before they are required.
A repeatable preparation system.
Preparation becomes less dependent on improvisation at the scene and more dependent on a clear system.
A shared layout.
Equipment is arranged to support a common mental model and quicker team orientation.
Less avoidable load.
The system reduces unnecessary searching, reorganisation and decision burden.9
Visible, checkable preparation.
Load lists and checklists make the system easier to inspect, maintain and improve.
Drugs, equipment and cognitive load
Equipment was only part of the story.
A significant proportion of preparation time is spent preparing drugs, and drug preparation is a recognised area of risk.
In anaesthesia and emergency care, errors involving drug selection, preparation, labelling or administration can have serious consequences. Jensen and colleagues recommended that drugs should be presented in prefilled syringes where possible, rather than ampoules, including for emergency drugs.8
Across services, emergency anaesthesia drugs may be prepared in different ways: pharmacy-prepared syringes, shift-prepared syringes, en-route preparation or preparation on scene. Each approach carries trade-offs.1,8
When a time-critical intervention depends on the right drug, in the right syringe, at the right concentration, under pressure, preparation is not an administrative detail. It is a safety-critical part of the system.
The SCRAM™ portfolio
Clinician feedback shaped the SCRAM™ portfolio.
As SCRAM™ was used across pre-hospital, hospital and specialist clinical environments, feedback from clinicians exposed the same preparation problem in different forms. The portfolio developed from that pattern.
Each configuration responds to a specific clinical context while retaining the same design philosophy: standardisation, visibility, sequencing, cognitive offloading, portability and reproducible team preparation.
The published evidence is strongest around emergency airway preparation, remote-site airway kit dump and paediatric implementation.
Research
Explore the research behind SCRAM™
For the deeper evidence base, publications, abstracts and implementation work, visit the Research — Emergency Airway Management page.
View research and publicationsThe central belief
Preparation is part of performance.
In emergency airway management, and across high-acuity, low-occurrence (HALO) procedures, the crisis does not begin with the first clinical action. It begins earlier — in the layout, the planned sequence, the prepared drugs, the shared mental model, the equipment check and every decision already lifted from the clinician’s cognitive load.
Clinical performance is not protected by asking clinicians to compensate harder.
It is protected by designing the conditions before the crisis.
References
- Swinton P, Corfield AR, Moultrie C, Percival D, Proctor J, Sinclair N, Perkins ZB. Impact of drug and equipment preparation on pre-hospital emergency anaesthesia (PHEA) procedural time, error rate and cognitive load. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2018;26:82. doi:10.1186/s13049-018-0549-3.
- Lockey D, Crewdson K, Davies G, Jenkins B, Klein J, Laird C, et al. AAGBI: safer pre-hospital anaesthesia 2017. Anaesthesia. 2017;72:379–390.
- Walz JM, Zayaruzny M, Heard SO. Airway management in critical illness. Chest. 2007;131(2):608–620.
- Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. British Journal of Anaesthesia. 2011;106:617–631.
- Schyma BM, Wood AE, Sothisrihari S, Swinton P. Optimising remote site airway management kit dump using the SCRAM bag — a randomised controlled trial. Perioperative Medicine. 2020;9:11. doi:10.1186/s13741-020-00140-w.
- Wylie M, Waters E, McCormack J, Swinton P. The SCRAM bag: a comparison between current practice versus a novel standardised approach for in-hospital paediatric emergency airway management. Critical Care. 2021;25(Suppl 1):P140.
- Pope J, Boyle J, Worrall M. Airway management in paediatric emergencies outside of an intensive care setting: a quality improvement project using Lean/Six Sigma methodology. Archives of Disease in Childhood — Education and Practice Edition. 2023;108:463–466. doi:10.1136/archdischild-2023-325329.
- Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;59(5):493–504.
- Hick WE. On the rate of gain of information. Quarterly Journal of Experimental Psychology. 1952;4(1):11–26.
- Durrand J, Batterham A, Danjoux G. Pre-habilitation (i): aggregation of marginal gains. Anaesthesia. 2014;69:403–406.