Lifting the Fogg on ED Intubaton

January 1, 2013 by  
Filed under All Updates, ICU, Resus

Fellow retrieval specialist and Royal North Shore Hospital emergency physician Dr Toby Fogg and coauthors have published their audit of intubations in an Australian Emergency Department(1). More important than the results themselves is that the process of monitoring ones practice inevitably leads to improvements. For example, at Toby’s institution an intubation checklist has been introduced since the audit began. Other Australasian EDs are encouraged to participate using the free resources at airwayregistry.org.au.

Recently we have also seen the publication of Korean registry data on paediatric intubations performed in 13 academic EDs over 5 years(2), in which first pass success rates (overall 67.6%) were higher with emergency physicians compared with paediatricians. Interestingly, a rapid sequence intubation technique was only used in 22.4% of intubations, which was more likely to be used by emergency physicians and was associated with a greater likelihood of first pass success.

This relatively low first pass success rate is reminiscent of the American study published in September(3) which raised some eyebrows with its 52% first pass intubation success rates in a paediatric ED, and which also showed that attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Possible reasons for such a low first pass success rate compared with adult registry data include the rigorous video analysis method used, or perhaps more likely that paediatric emergency subspecialists are exposed to fewer critical procedures, resuscitations, and intubations than their general emergency medicine counterparts(4).

As a specialty we must continue to seek to do better, and I salute all these brave authors who are telling it like it is. Particularly with children, whose airways are relatively easy, we have to develop the training, preparation, supervision, monitoring and feedback to aim for as high a success rate as possible.

Study authors Toby Fogg and Nick Annesley demonstrate the 'Happiness Triad'

1. Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia
Emerg Med Australas. 2012 Dec;24(6):617-24


OBJECTIVE: To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.

METHODS: A prospective observational study.

RESULTS: Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken.

CONCLUSION: Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.

2. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study
Resuscitation. 2012 Nov;83(11):1363-8


BACKGROUND: We investigated which factors are associated with successful paediatric endotracheal intubation (ETI) on the first attempt in emergency department (EDs) from multicentre emergency airway registry data.

METHODS: We created a multicentre registry of intubations at 13 EDs and performed surveillance over 5 years. Each intubator filled out a data form after an intubation. We defined “paediatric patients” as patients younger than 10 years of age. We assessed the specialty and level of training of intubator, the method, the equipment, and the associated adverse events. We analysed the intubation success rates on the first attempt (first-pass success, FPS) based on these variables.

RESULTS: A total of 430 ETIs were performed on 281 children seen in the ED. The overall FPS rate was 67.6%, but emergency medicine (EM) physicians showed a significantly greater success rate of 74.4%. In the logistic regression analysis, the intubator’s specialty was the only independent predictive factor for paediatric FPS. In the subgroup analysis, the EM physicians used the rapid sequence intubation/intubation (RSI) method and Macintosh laryngoscope more frequently than physicians of other specialties. ETI-related adverse events occurred in 21 (7.2%) out of the 281 cases. The most common adverse event in the FPS group was mainstem bronchus intubation, and vomiting was the most common event in the non-FPS group. The incidence of adverse events was lower in the FPS group than in the non-FPS group, but this difference was not statistically significant.

CONCLUSIONS: The intubator’s specialty was the major factor associated with FPS in emergency department paediatric ETI, The overall ETI FPS rate among paediatric patients was 67.6%, but the EM physicians had a FPS rate of 74.4%. A well structured airway skill training program, and more actively using the RSI method are important and this could explain this differences.

3.Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Ann Emerg Med. 2012 Sep;60(3):251-9


STUDY OBJECTIVE: Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED).

METHODS: We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success.

RESULTS: We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined.

CONCLUSION: Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

4. A is for airway: a pediatric emergency department challenge.
Ann Emerg Med. 2012 Sep;60(3):261-3

Comments

3 Responses to “Lifting the Fogg on ED Intubaton”

  1. Viking One, alias Dr. Per P. Bredmose on January 1st, 2013 18:31

    Hi
    This is SAD reading… but great that the authors admits it (and Cliff puts it on his blog)..
    With first pass numbers of 67% and as low as 52% in kids NO ONE should FU..ING NEVER approach my kids or someone in my family with a laryngoscope and a syringe with dangerous drugs that makes you stop breathing….. NEVER…
    If this represents the standards, the skills, the level of care in ED there is a desperate need for both training and development and second thoughts about WHO SHALL INTUBATE / manage airways in living people (cardiac arrest is a different story)…
    Good that someone takes a closer look a this – but are staff involved (I have NOT mentioned any particular specialities here.. but…. (no no different story for another day) ready to face and accept the concequences…
    PS: Actions would be taken rather fast in aviation with similar numbers for landings and “go arounds” !

  2. Cliff on January 2nd, 2013 09:30

    From Tim Leeuwenburg of http://www.ki-docs.com:

    Good on Toby and colleagues for (a) setting up the airway audit and (b) publishing results

    This really gets to the core of it for me. Are we ‘good enough’ at emergency intubation? And if not, why not?

    Of course, in a tertiary ED there should always be the option of calling someone else (consultant in EM or anaesthetist). I’d argue that securing the airway remains a core EM skill. However, there is not the option to call for help in rural Oz, where rural doctors (some with anaesthetic skills, some without) need to manage airways WITHOUT immediate support

    Given that critical illness does not respect geography, I’d love to see (a) audits of how good (or bad) us rural docs are at first pass emergency laryngoscopy and (b) a commitment to audit and improvement…including adequate equipment and training

    Thoughts?”

    Tim Leeuwenburg
    Kangaroo Island

    http://www.ki-docs.com

    Twitter @KangarooBeach

  3. Casey on January 4th, 2013 10:35

    Thanks for this great work Toby and co.
    We have been using your tool to collect data in our small rural ED
    Numbers are small – but the benefits of audit and comparison will no doubt lead to improvements in systems, team setup and techniques
    Casey