Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM)

Abstract

Background Pre hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic—termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM. Methods A retrospective observational study of consecutive trauma patients ≥ 16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015–2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher’s exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95% CI)), p value. The study design complied with the STROBE (Strengthening The Reporting of Observational studies in Epidemiology) reporting guidelines. Results In the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥ 16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28–63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs—90.2% and 87.4% respectively, OR 1.3 (95% CI 0.7–2.5), p = 0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt. Conclusion In an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.

The effect of a multi-faceted quality improvement program on paramedic intubation success in the critical care transport environment: a before-and-after study

“…We believe that the increase in FPS rate from 60 to 86% (for the pre- and post-intervention period, respectively) proves the effectiveness of our organization’s AAM QIP. While the post-intervention results are encouraging, they are also comparable to previously published FPS rates from other prehospital or retrieval services [ 10 , 18 – 20 ]. Our explorative analysis suggests that the organizational direction from DFI towards RSI and the introduction of VL might have contributed to increasing FPS rates.…”

“…A randomized controlled trial comparing intubation with Midazolam and Etomidate, without paralytics in both groups, demonstrated a low overall intubation success rate of only 76% [ 23 ]. This contrasts with multiple large case series of prehospital RSIs, where overall intubation success rates trend towards 100% [ 12 , 18 , 20 ]. Prehospital RSI is the recommended strategy for prehospital intubations (other than in cardiac arrest or peri-arrest situations) by the Association of Anaesthetists of Great Britain and Ireland [ 2 ].…”

Paediatric Major Trauma: A Retrospective Observational Comparison of Mortality in Prehospital Bypass and Secondary Transfer in the East of England

“…For patients with critical needs, despite triggering the MTTT, EMS are instructed to transport patients to the nearest TU for stabilization [11]. In addition, permission to bypass in other situations can be requested through communication with the Network Co-ordination Service (NCS) which is led by an emergency medicine consultant; in practice, this method is only regularly utilized by the regional physician-led Helicopter Emergency Medical Services (HEMS) [12].…”

“…Owing to data access constraints across multiple sites, these data were obtained from a single MTC in the East of England region, potentially resulting in a selection bias of the most seriously injured patients across a 20,000 km 2 inclusive trauma network [12]. The study was also limited by the nature of a retrospective review with some missing data (including physiological data) and a chance of reporting bias.…”

Nine golden codes: improving the accuracy of Helicopter Emergency Medical Services (HEMS) dispatch—a retrospective, multi-organisational study in the East of England

“…The primary rationale for HEMS is the rapid deployment of a specialist team over a large geographic area, with the assumption that physicians working alongside paramedics infer better patient outcomes compared to paramedics alone. The latter point is multi-factorial, and includes higher-level decision-making [ 2 , 3 ], and interventions that are either physician-level specific or require drugs that legally require their presence [ 3 – 5 ]; an example in the UK is prehospital emergency anaesthesia (PHEA) [ 6 , 7 ]. There is contradictory evidence that physician-staffed teams are associated with better patient outcomes following trauma [ 8 – 14 ], and out-of-hospital cardiac arrest [ 15 – 18 ].…”