quality assurance of pre-hospital endotracheal intubation

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

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BackgroundETI as “gold standard” of airway care in unconscious patientsProvide secured airway during transportOptimize oxygenation and ventilationPulmonary toiletingRoute of drugs administration

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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

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Current ControversyModify patient outcome

Beneficial vs harmfulMode of trainingSkill retentionDrug-assisted intubationAlternative airways

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ObjectivesPrimary Objective:

Ottawa’s pre-hospital ETI success rateSecondary Objective:

To identify potential barriers and complications

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MethodsRetrospective review of Ambulance Call Reports (ACRs) involving invasive airway management by ACPsStudy period: July 1st 2003 - July 31st 2005

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DefinitionsAge:

Adults: >=8 yrs oldChildren: < 8 yrs old

AHA ACLS 2000

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DefinitionsETI attempt

ETT beyond oro-pharynx

ETI successETT position confirmed clinically and be able to ventilate through it

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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

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Data sourceAmbulance Call Reports

Mandatory reports (>95%)

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Inclusion criteriaAll patients attended during the study period by Ottawa ACPs

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Exclusion criteriaETI not performed by ACPsInter-provincial transferInter-facilities transferPhysicians on scene

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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

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Statistical analysisDescriptive statistical analysisUnivariate analysis on demographics dataLogistic regression to determine environmental barriers and complications

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Total ACRs

118856

Non-intubated Patients117793

Intubated Patients1029

LMA only34

Non-transported514

Transported515

Study enrollment flowchart

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Patient demographics

5155141029Total ACRs

909Pediatrics

5035101013Adults

297343640Sex (M)

TransportedNon-transportedTotal

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Patient demographicsAge:

Median 69, range (0-97)

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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

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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

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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

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Route of ETI on 1st attempts

0102030405060708090

100

Overall Non-transported

Transported

NasalOral

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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%

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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

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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

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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)

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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)

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Success in 1st attempts

0.080Pre-intubated GCS (3 vs >3)

0.182Nature EMS calls

0.0280Gender

0.055Age

p valuesDescriptive data

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Factors influencing overall success

<0.001VSA

0.003Pre-intubation GCS (3 vs >3)

p valvesDescriptive data

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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)

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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

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DiscussionPositive predicting variables of success

VSAPre-intubation GSC=3

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DiscussionNegative predicting variables of success

Combative, alert patientsUnable to visualize vocal cords

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DiscussionComplication rate was 3.2%, excluding equipment issuesEquipment failure and vomiting were common complications

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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

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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

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Future

National standardized ETI data collectionMulti-centers collaboration on children

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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.

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AcknowledgementsGrant support from the Department of Emergency Medicine Academic Funds for 2005 Special Projects, University of Ottawa, OntarioOttawa Paramedic ServiceOttawa Base Hospital Program

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Study partners