Elsevier

Resuscitation

Volume 58, Issue 1, July 2003, Pages 49-58
Resuscitation

Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation

https://doi.org/10.1016/S0300-9572(03)00058-3Get rights and content

Abstract

Study Objective: Previous out-of-hospital airway management data are limited by small, single-site designs. We sought to evaluate the feasibility of performing a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation (ETI) using a standardized data collection tool. Methods: We designed a prospective multi-centered observational study involving 45 advanced life support (ALS) services from a mid-Atlantic state. Using a standardized data form, prehospital personnel reported details of each attempted ETI, including patient demographics, methods used, difficulties encountered, and initial patient outcomes. We calculated and assessed data form return rates (using independent queries of the number of ETI attempted by each EMS service) and missing data entry rates. We also performed preliminary cross-sectional assessments of factors of current interest in out-of-hospital ETI. Accuracy and validity of responses were not evaluated. Data were stored centrally and analyzed using descriptive techniques. Results: Participants included 8 urban, 15 suburban, 20 rural, and 2 air medical services. Data forms were received on 783 adults receiving ETI attempts during the study period June 1, 2001–November 30, 2001. The pooled data form return rate was 72.7%. Per-service return rates ranged from 0 to 100% and the median per-service return rate was 75%. Non-response (data form not returned for attempted intubation) was problematic, with nine services demonstrating data return rates less than 50%. Data return rates could not be calculated for an additional nine services. The missing data entry rate was 0.5–22.2%. The overall reported ETI success rate was 86.8% (92.8% for cardiac arrests and 76.8% for non-arrests) and did not appear to vary between population settings. There were two cases of delayed recognition of esophageal intubation, one case of unrecognized esophageal intubation, and 22 cases of tube dislodgement during patient care or transport. Bag-valve-mask ventilation was used as the rescue airway technique in the majority of failed ETI. When stratified for cardiac arrests vs. non-arrests, ETI success was not associated with field or initial ED survival. Conclusions: We successfully obtained complete data for the majority of ETI attempted across multiple EMS services. Our data also indicate the need to address problems with non-response. Preliminary cross-sectional data highlight areas of current interest in out-of-hospital airway management.

Sumàrio

Objectivos do estudo: Os dados disponı́veis sobre a abordagem da via aérea fora do hospital são limitados a pequenos estudos num único local. Avaliou-se a possibilidade de realizar uma avaliação multicêntrica, prospectiva da entubação endotraqueal (ETI) fora do hospital através de um modelo uniforme de recolha dos dados. Métodos: Foi desenhado um estudo observacional prospectivo multicêntrico envolvendo 45 serviços prestadores de cuidados de Suporte Avançado de Vida (ALS) de um estado do Médio-Atlântico. Através da utilização de um boletim padronizado para recolha dos dados, o pessoal pré-hospitalar referiu detalhes de cada tentativa de ETI, incluindo dados demográficos dos pacientes, métodos utilizados, dificuldades encontradas e prognóstico inicial dos doentes. Foram calculados e avaliados os dados da taxa de retorno (utilizando inquéritos independentes do número de ETI tentadas por cada Serviço de Emergência Médica (SEM)) e taxa de dados omissos. Também foi feita uma avaliação preliminar, num grupo representativo, dos factores de interesse corrente na ETI fora do hospital. A precisão e a validade das respostas não foi avaliada. Os dados foram armazenados num centro e analisados utilizando técnicas descritivas. Resultados: Os serviços médicos participantes eram provenientes de 8 serviços médicos urbanos, 15 suburbanos, 20 rurais e 2 aéreos. Obtiveram-se boletins de 783 adultos nos quais tinha sido tentada a ETI durante o perı́odo de estudo, 1 de Junho a 30 de Novembro de 2001. A taxa de retorno dos boletins com os dados foi de 72.7%. A taxa de retorno por serviço variou dos 0 aos 100%, sendo 75%. a taxa de retorno média por serviço. O número de não respostas (boletim relativo a tentativa de entubação não devolvido) foi problemático, com nove serviços demonstrando taxas de retorno de dados inferiores a 50%. A taxa de retorno não pôde ser calculada para outros 9 serviços. A taxa de dados não registados foi 0.5-22.2%. A taxa global de sucesso da ETI referida foi de 86.8% (92.8% para a paragem cardı́aca e 76.8% para outras situações que não a paragem) e não parecia variar de acordo com as caracterı́sticas da população analisadas. Identificaram-se dois casos de reconhecimento tardio de entubação esofágica, um caso de entubação esofágica não reconhecida, e 22 casos de deslocação do tubo durante tratamento ou transporte. A ventilação com insuflador e máscara foi utilizada como a técnica de manipulação da via aérea na maioria das ETI falhadas. O sucesso da ETI não se associou à sobrevivência no local ou inicial no DE (Departamento de Emergência), quando estratificada para paragem cardı́aca vs não paragem cardı́aca. Conclusões: Foram obtidos dados com sucesso na maioria das tentativas de ETI nos múltiplos serviços SEM. Os dados recolhidos também indicam a necessidade de chamar a atenção para problemas que ainda sem resposta. Os dados preliminares deste grupo representativo realçam áreas de interesse corrente na manipulação da via aérea fora do hospital.

Resumen

Objetivos del estudio: Estudios previos acerca de manejo extrahospitalario de vı́a aérea se limitan a estudios pequeños, diseñados en un solo sitio. Tratamos de evaluar la factibilidad de realizar una evaluación prospectiva, multicéntrica, de la intubación endotraqueal(ETI) en el prehospitalario usando una herramienta estandarizada para la colección de datos. Métodos: Diseñamos un estudio observacional prospectivo multicéntrico involucrando 45 servicios de soporte vital avanzado(ALS) de un estado centroatlántico. El personal prehospitalario reportó los detalles de cada intento de IOT usando un formulario estandarizado, incluyendo datos demográficos del paciente, métodos usados, dificultades encontradas, y resultados iniciales del paciente. Calculamos y evaluamos datos de los formularios retornados (usando valores independientes del numero de ETI intentados por cada servicio de emergencias médicas) y tasas de datos faltantes. También realizamos una evaluación seccional transversa de los factores de interés común en la intubación traqueal en el prehospitalario. No se evaluó la exactitud y validez de las respuestas. Los datos fueron almacenados centralmente y analizados usando técnicas descriptivas. Resultados: Los participantes incluyeron 8 servicios médicos urbanos, 15 suburbanos, 20 rurales y 2 aéreos. Se recibieron los datos de 783 adultos en quienes se realizaron intentos de intubación traqueal durante el perı́odo de estudio, entre el 1° de Junio y 30 de Noviembre 30 de 2001. Los datos acumulados forman una razón de retorno de 72.7%. Las razones de retorno por servicio variaron entre 0 y 100% con una mediana de 75%. La presencia de no- respuesta (formulario de datos no retornado para intubación intentada) fue problemática, con 9 servicios mostrando una razón de retorno menor de 50%. Las razones de retorno no pudieron ser calculadas para otros 9 servicios adicionales. La razón de datos faltantes fue de 0.5–22.5%.La tasa de éxito reportada en todo el grupo fue de 86.8% (92.8% en paro cardı́aco y 76.8% en casos sin paro) y no parece variar entre los distintas ambientes poblacionales. Hubo 2 casos de reconocimiento tardı́o de intubación esofágica, un caso de intubación esofágica no diagnosticado, y 22 casos de desplazamiento del tubo fuera de la traquea durante el traslado o manejo del paciente. La ventilación con bolsa de resucitación fue usada como técnica de rescate en la mayorı́a de los casos de intubación traqueal fallida. Cuando se separan por paro cardı́aco o sin paro cardı́aco, el éxito de la intubación no se asoció con sobrevida en la escena o inicial en el departamento de emergencias. Conclusiones: Obtuvimos exitosamente datos completos para la mayorı́a de los intentos de intubación traqueal en múltiples servicios de emergencias médicas. Nuestros datos también indican la necesidad de abordar problemas sin respuesta. Los datos preliminares de corte transversal destacan áreas de actual interés en manejo extrahospitalario.

Introduction

Endotracheal intubation (ETI) has been performed on critically-ill out-of-hospital patients for over 20 years [1], [2], [3]. However, recent studies have suggested the need to re-examine how this procedure is performed in the field setting [4], [5]. There are many published studies of out-of-hospital intubation, but these studies are inadequate in the light of current demands for evidence-based approaches to prehospital medical practice [6], [7], [8], [9]. Previous studies of field ETI used retrospective, single-site designs with inconsistent terminology and inadequate scope or detail [1], [2], [10], [11], [12]. Prior studies have also provided only limited insights regarding issues of interest in current prehospital airway management; for example, complications encountered during ETI and the effect of prehospital ETI upon patient survival.

In this preliminary study we sought to evaluate the feasibility of obtaining prospective, multi-centered data examining current out-of-hospital airway management practices. We had two specific goals: (1) to evaluate the use of a standard data reporting tool to capture pertinent details regarding the course of ETI attempted by multiple EMS services operating in differing patient population settings under varying clinical protocols, and (2) to provide preliminary estimates of factors of current interest in out-of-hospital airway management.

Section snippets

Methods

We used a prospective, multi-centered observational design involving 45 advanced life support (ALS) EMS services from across the Commonwealth of Pennsylvania. Participating services included units in urban, suburban, rural, and air medical settings. All services used independent personnel, medical direction and clinical protocols; at the time of this study, statewide medical protocols had not yet been enacted. Service staffing practices included both all career and career/volunteer

Results

The 45 EMS services participating in the study included 8 urban, 15 suburban, 20 rural, and 2 air medical services. Data forms were made available to all ALS units in 44 services. (In one ground service, data forms were inadvertently distributed to only selected rescuers rather than being placed on all ambulances.) The study services served a total population of approximately 1 870 000 over a geographical area of 12 000 mile2, and included a total of 1350 ALS personnel with over 150 000

Discussion

Broadly-applicable inferences regarding out-of-hospital ETI can be difficult to make because of variations in patient and population settings, protocols, staffing configurations, and documentation practices. Previous evaluations of out-of-hospital ETI have generally been limited to retrospective, single EMS service reviews [1], [2], [10], [11], [12]. Prospective collection of multi-centered data is desirable because it bridges variations across different practice settings and provides

Acknowledgements

This study was supported by a grant from The Pittsburgh Emergency Medicine Foundation, Pittsburgh, Pennsylvania. The authors acknowledge Donald Holsten, NREMT-P, James Traub, NREMT-P, and Mark Pinchalk, BS, EMT-P, for their special assistance with study center recruitment and coordination. We acknowledge Elizabeth Peitzman for her assistance in data entry and analysis. We acknowledge the assistance of the Commonwealth of Pennsylvania, Department of Health EMS Office, Margaret Trimble, B.S.N.,

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