IntroductionFirst attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt.MethodsLifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics.ResultsOf the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid.ConclusionAlthough a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.

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Objective Critically unwell patients in rural and remote areas of Queensland, Australia, often require airway management with rapid sequence intubation (RSI) prior to retrieval to a tertiary centre. Retrieval Services Queensland (RSQ) coordinate retrievals and support rural hospitals, including via telehealth. We aimed to describe the demographics of patients intubated in Queensland hospitals requiring subsequent aeromedical retrieval. This retrospective cohort study compared patients intubated by a retrieval team, including a LifeFlight Retrieval Medicine (LRM) doctor, to those intubated by the local hospital team. MethodsRetrospective cohort study of all patients intubated in hospitals in Queensland, Australia, requiring subsequent aeromedical retrieval (including an LRM doctor) between January 2019 and December 2019. Data collected included: time of day, mission priority, geographical location of hospital, rurality, diagnosis, failure/assistance with intubation. Descriptive statistics were complemented by logistic regression analyses. Results In 2019, 684 patients were intubated in hospitals in Queensland, Australia, requiring subsequent aeromedical retrieval by a team including an LRM doctor. 131 (19.2%) were intubated by the retrieval team, and 553 (80.8%) were intubated by the local hospital team. The retrieval team was more likely to intubate as the age of the patient increased. In the most rural and remote areas, 64 (43.2%) of patients were intubated by the retrieval team, compared with 84 (56.8%) by the local team. In this subgroup of rural and remote patients, the composite diagnosis of ‘injuries, poisons, toxicology and drugs’ was significantly more likely to be associated with the local team intubating. ConclusionA retrieval team is more likely to be required for intubation of patients in rural and remote hospitals in Queensland, Australia. Service provision for critically unwell patients, coordinated by RSQ, is effective and well-managed. Rural and remote hospitals should be given special preference and consideration for timely dispatch of the retrieval team for assistance with these cases.Trial RegistrationEthical approval for this project was granted by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee (LNR/2020/QRBW/64917). A waiver of consent was granted given the retrospective and deidentified nature of the study.