A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic

Abstract

Objective Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba’s largest tertiary hospital. During this study, a natural experiment emerged when a standardized “COVID-Protected Rapid Sequence Intubation Protocol” was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a “COVID-Protected Rapid Sequence Intubation Protocol” impact first-pass success or other intubation-related outcomes? Methods A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack–Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days. Results Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% ( n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% ( n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack–Lehane view favoring the protocol ( p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol ( p = 0.0172). Conclusion A “COVID-Protected Protocol” implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events. Supplementary Information The online version contains supplementary material available at 10.1007/s43678-022-00422-w.

Introduction of Infection Prevention Tracheal Intubation Protocol during the COVID-19 Pandemic Is Not Associated with First-Pass Success Rates of Endotracheal Intubation in the Emergency Department: A Before-and-After Comparative Study

“…Thirdly, the high VL usage rate may have contributed to the sustained FPS levels. Multivariate analysis showed that VL was independently significantly associated with FPS, and several other studies have supported the relationship between high VL use and high FPS [15,20,25,27,30]. In addition, VLs have a clear advantage over DLs in the donning of PPE [25,36].…”

“…Multivariate analysis showed that VL was independently significantly associated with FPS, and several other studies have supported the relationship between high VL use and high FPS [15,20,25,27,30]. In addition, VLs have a clear advantage over DLs in the donning of PPE [25,36]. Although portable VLs with smaller screens were used significantly more during the pandemic period, the OR for FPS was not different from that for mounted VLs with larger screens (OR 2.12 vs. 2.16).…”

“…Therefore, investigating the association between new protocols and FPS of intubation will help us prepare for other infectious disease pandemics in the future. To date, a few ED-based studies have reported their experience with ETI protocols to prevent infection during the COVID-19 pandemic [ 25 , 26 , 27 ]. However, more research is needed on this topic to draw universal conclusions that can be applied to different ED settings [ 4 , 8 , 25 , 26 , 27 , 28 , 29 , 30 ].…”

Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN)

“…The impact of intubator experience may have played a role in the high rate of first-pass success observed (as many position statements recommended the most experienced available provider perform intubations) but this variable was not available in the CCEDRRN registry. Studies comparing pre- and post-COVID-19 intubation practices found intubator experience to be positively associated with first-pass success [ 22 ]. First-pass success is an operational surrogate for patient outcomes [ 23 ], with multiple intubation attempts having been associated with increased adverse events and complications [ 4 , 23 , 24 ].…”

Assess the Modified Early Warning Score (MEWS) in Predicting Critical Care Unit Admission Among Patient in Emergency Department at Saveetha Medical College and Hospital, Thandalam

“…It can help identify patients who are more likely to experience clinical deterioration and who require close supervision, early transfer for critical care, or other timely interventions. Thus, the use of MEWS in medical emergency units might be a helpful tool to enhance patient care, guarantee optimal resource utilisation, and avoid neglecting or improperly discharging unwell patients 8 The National Early Warning Score outperformed the other scores in predicting ICU admission, while the Modified Early Warning Score outperformed the other severity levels in predicting hospital mortality 9. Modified early warning scoring systems may be used in emergency rooms to anticipate patient clinical outcomes at the time of the initial examination and can also be a useful tool for determining the patients' prognosis 10 This study was conducted to assess and associate the Modified Early Warning Score (MEWS) in predicting critical care unit admission among patient in emergency department.…”