quality assurance of pre-hospital endotracheal intubation
Post on 10-May-2022
1 Views
Preview:
TRANSCRIPT
Quality Assurance Of Pre-hospital Endotracheal Intubation Performed
By Advanced Care Paramedics (ACPs) In Ottawa, Canada
Ron Tam MD1,2, Justin Maloney MD1,2, Isabelle Gaboury PhD(C )4, Jeannette Verdon BScApp2, John Trickett BScN2,
Shannon Leduc ACP3, Pierre Poirier ACP MBA3
1Departments of Emergency Medicine and Pediatrics, University of Ottawa
2Ottawa Base Hospital Program3Ottawa Paramedic Service
4Chalmers Research Group, CHEO Research Institute
Nov 2006 OPALS Meeting Ottawa
BackgroundETI as “gold standard” of airway care in unconscious patientsProvide secured airway during transportOptimize oxygenation and ventilationPulmonary toiletingRoute of drugs administration
Nov 2006 OPALS Meeting Ottawa
Success & outcome
Yes7.0NT/OTN75.0Krisanda
All7.0OTYes64.0Aijan
No31.3OTYes93.5Pointer
Yes5.1OTNA90.6Delec
AllNAOTNo76.5Losek
All7.4OTYes88.9Pointer
NANAOTMainly96.6Jacobs
NA13.0NTNo71.3O’Brian
NA9.5OTYes90.9Stewart
PediatricsCompNT/OTArrest/ coma
SuccessRateStudy
Nov 2006 OPALS Meeting Ottawa
Current ControversyModify patient outcome
Beneficial vs harmfulMode of trainingSkill retentionDrug-assisted intubationAlternative airways
Nov 2006 OPALS Meeting Ottawa
ObjectivesPrimary Objective:
Ottawa’s pre-hospital ETI success rateSecondary Objective:
To identify potential barriers and complications
Nov 2006 OPALS Meeting Ottawa
MethodsRetrospective review of Ambulance Call Reports (ACRs) involving invasive airway management by ACPsStudy period: July 1st 2003 - July 31st 2005
Nov 2006 OPALS Meeting Ottawa
DefinitionsAge:
Adults: >=8 yrs oldChildren: < 8 yrs old
AHA ACLS 2000
Nov 2006 OPALS Meeting Ottawa
DefinitionsETI attempt
ETT beyond oro-pharynx
ETI successETT position confirmed clinically and be able to ventilate through it
Nov 2006 OPALS Meeting Ottawa
Study targetAdvanced Care Paramedics (ACPs)
150 ACPs in Ottawa regionScope of practice
ACLSSymptoms relief intervention
Perform pre-hospital endotracheal intubation (ETI) as clinically indicatedNon DAI
Nov 2006 OPALS Meeting Ottawa
Data sourceAmbulance Call Reports
Mandatory reports (>95%)
Nov 2006 OPALS Meeting Ottawa
Inclusion criteriaAll patients attended during the study period by Ottawa ACPs
Nov 2006 OPALS Meeting Ottawa
Exclusion criteriaETI not performed by ACPsInter-provincial transferInter-facilities transferPhysicians on scene
Nov 2006 OPALS Meeting Ottawa
Method (Data collection)3 independent chart extractors Reviewed all eligible ACRs, and transcribed onto a predetermined data entry formConflicting of interpretation was resolved by agreement between the two principle investigators
Nov 2006 OPALS Meeting Ottawa
Statistical analysisDescriptive statistical analysisUnivariate analysis on demographics dataLogistic regression to determine environmental barriers and complications
Nov 2006 OPALS Meeting Ottawa
Total ACRs
118856
Non-intubated Patients117793
Intubated Patients1029
LMA only34
Non-transported514
Transported515
Study enrollment flowchart
Nov 2006 OPALS Meeting Ottawa
Patient demographics
5155141029Total ACRs
909Pediatrics
5035101013Adults
297343640Sex (M)
TransportedNon-transportedTotal
Nov 2006 OPALS Meeting Ottawa
Patient demographicsAge:
Median 69, range (0-97)
Nov 2006 OPALS Meeting Ottawa
Nature of EMS calls
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Studied ACRs
Medical PtsTrauma PtsOthers
Nov 2006 OPALS Meeting Ottawa
Overall successful attempts
77.7%86.3%82.1%Adults
77.8%NA77.8%Children
69.1%75.0%69.8%Trauma Pts
78.4%86.7%82.4%Medical Pts
85.7%86.7%86.3%VSA
77.6%86.4%82.1%Overall ACRs
Success rate in Transported
Success rate in non-transported
Overall successrate
Nov 2006 OPALS Meeting Ottawa
Success in first attempts
22.2%NA22.2%Children
63.6%66.3%65.0%Adults
54.8%0%53.5%Trauma Pts
63.4%67.3%65.3%Medical Pts
67.8%66.5%67.0%VSA
62.7%66.5%63.6%Overall
Transportedsuccess rate
Non-transportedsuccess rate
Overall ACRssuccess Rate
Nov 2006 OPALS Meeting Ottawa
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
East 75.6% 99.4% 51.8%
Overall Non-transported Transported
VSA patients on 1st ETI attempts
Nov 2006 OPALS Meeting Ottawa
Route of ETI on 1st attempts
0102030405060708090
100
Overall Non-transported
Transported
NasalOral
Nov 2006 OPALS Meeting Ottawa
Success: oral vs nasal route on 1st attempts
Overall Non-transported
Transported
Nasal route 54.7% NA 54.97%
Oral route 66.1% 66.54% 65.84%
Nov 2006 OPALS Meeting Ottawa
Success rates in sequentialattempts and cumulative attempts
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
1st 2nd 3rd 4th 5th
Individual attempt
Individual SR Cumulative SR
Nov 2006 OPALS Meeting Ottawa
Complications reported during ETI
0 50 100 150 200
Equip failure
Vomiting
Displaced ETTduring transport
Missing equip
Laryngospasm
Others
Number of incidence reported(Total n = 1029)
End tidal CO2monitor
Nov 2006 OPALS Meeting Ottawa
Environmental barriers reported during ETI
0 20 40 60 80 100 120
Problem with access
Lack of room
Snow/rain/fire
Hostile bystander
Poor lighting
Trapped in vehicle
No. of evironmental barriers reported(Total n = 1029)
Nov 2006 OPALS Meeting Ottawa
Reported patient barriers during ETI
0 50 100 150 200 250 300
Foreign body / fluid in airway
Unable to visualize cords
Clenched jaw trismus
Intact gag reflex
C spine collar
Oral / facial trauma
Combative pt
Short neck
Ant cords
Inadeq relax
Others
No. of pt barriers reported(Total n = 1029)
Nov 2006 OPALS Meeting Ottawa
Success in 1st attempts
0.080Pre-intubated GCS (3 vs >3)
0.182Nature EMS calls
0.0280Gender
0.055Age
p valuesDescriptive data
Nov 2006 OPALS Meeting Ottawa
Factors influencing overall success
<0.001VSA
0.003Pre-intubation GCS (3 vs >3)
p valvesDescriptive data
Nov 2006 OPALS Meeting Ottawa
Regression analysis of barriers and complications on ETI success
0.00 0.25 0.50 0.75 1.00
T- clenched jaw
T-unable visualize cords
NT-unable visualize cords
T-ant cord
T- FB
T- Intact gag
T- short/fat neck
T- hostile bystander
T-vomit
Odds ratio (95%CI)
Nov 2006 OPALS Meeting Ottawa
Discussion
Our ETI success rate of 82.1% is consistent with rates reported in the literatureThere is no significant improvement in success rates after the 2nd attempt
Nov 2006 OPALS Meeting Ottawa
DiscussionPositive predicting variables of success
VSAPre-intubation GSC=3
Nov 2006 OPALS Meeting Ottawa
DiscussionNegative predicting variables of success
Combative, alert patientsUnable to visualize vocal cords
Nov 2006 OPALS Meeting Ottawa
DiscussionComplication rate was 3.2%, excluding equipment issuesEquipment failure and vomiting were common complications
Nov 2006 OPALS Meeting Ottawa
ConclusionOngoing QA of pre-hospital ETI is critical to ensure successful airway managementPatient and environmental barriers to ETI success can be identifiedProtocols and training for pre-hospital ETI must consider a risk stratification approach
Nov 2006 OPALS Meeting Ottawa
LimitationsRetrospective chart review on ACRs; quality of the chart documentation variedLack of independent field validation on ETI confirmationNo hospital data on transported patientsOutcome measurement limited to documented intubation success
Nov 2006 OPALS Meeting Ottawa
Future
National standardized ETI data collectionMulti-centers collaboration on children
Nov 2006 OPALS Meeting Ottawa
References1Krisanda TJ, Eitel DR, et al: An analysis of invasive airway management in a suburban emergency medical services system. PrehospDisaster Med. 1992; 7(2): 121-6.2Wang HE, Kupas DF, et al: Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation. Resuscitation. 2003; 58(1):49-58.
Nov 2006 OPALS Meeting Ottawa
AcknowledgementsGrant support from the Department of Emergency Medicine Academic Funds for 2005 Special Projects, University of Ottawa, OntarioOttawa Paramedic ServiceOttawa Base Hospital Program
Nov 2006 OPALS Meeting Ottawa
Study partners
top related