Paramedic Perceptions of Challenges in Out-of-Hospital Endotracheal Intubation

Thomas, Jane Boyce; Abo, Benjamin N.; Wang, Henry E.

doi:10.1080/10903120701205802

Cited by 19 publications

(16 citation statements)

References 22 publications

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“…Several studies have focused on the intricacy of implementing TI in the pre-hospital setting [21-23]. TI represents a complex intervention (Figure 2) that contains several separate but highly interacting components.…”

Section: Discussionmentioning

confidence: 99%

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

et al. 2011

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IntroductionAlthough tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures, providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables and 12 fixed-system variables) found in current scientific publications on pre-hospital TI.MethodsWe performed an all time systematic search according to the PRISMA guidelines of Medline and EMBASE to identify original research pertaining to pre-hospital TI in adult patients.ResultsFrom 1,076 identified records, 73 original papers were selected. Information was extracted according to an Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR 8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most frequently reported variables were "patient category" and "service mission type", reported in 86% and 71% of the studies, respectively. Among the least-reported variables were "co-morbidity" and "type of available ventilator", both reported in 2% and 1% of the studies, respectively.ConclusionsCore data required for proper interpretation of results were frequently not recorded and reported in studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design must be improved to substantiate future evidence based clinical practice.

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Section: Discussionmentioning

confidence: 99%

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

et al. 2011

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“…Because EMS rescuers view tracheal intubation as an essential skill, widespread adoption of alternate airways would require major shifts in EMS operations and culture. 55 …”

Section: Discussionmentioning

confidence: 99%

Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes

Wang

Balasubramani

Cook

et al. 2010

Annals of Emergency Medicine

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Study objective Previous studies suggest improved patient outcomes for providers who perform high volumes of complex medical procedures. Out-of-hospital tracheal intubation is a difficult procedure. We seek to determine the association between rescuer procedural experience and patient survival after out-of-hospital tracheal intubation. Methods We analyzed probabilistically linked Pennsylvania statewide emergency medicine services, hospital discharge, and death data of patients receiving out-of-hospital tracheal intubation. We defined tracheal intubation experience as cumulative tracheal intubation during 2000 to 2005; low=1 to 10 tracheal intubations, medium=11 to 25 tracheal intubations, high=26 to 50 tracheal intubations, and very high=greater than 50 tracheal intubations. We identified survival on hospital discharge of patients intubated during 2003 to 2005. Using generalized estimating equations, we evaluated the association between patient survival and out-of-hospital rescuer cumulative tracheal intubation experience, adjusted for clinical covariates. Results During 2003 to 2005, 4,846 rescuers performed tracheal intubation. These individuals performed tracheal intubation on 33,117 patients during 2003 to 2005 and 62,586 patients during 2000 to 2005. Among 21,753 cardiac arrests, adjusted odds of survival was higher for patients intubated by rescuers with very high tracheal intubation experience; adjusted odds ratio (OR) versus low tracheal intubation experience: very high 1.48 (95% confidence interval [CI] 1.15 to 1.89), high 1.13 (95% CI 0.98 to 1.31), and medium 1.02 (95% CI 0.91 to 1.15). Among 8,162 medical nonarrests, adjusted odds of survival were higher for patients intubated by rescuers with high and very high tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.55 (95% CI 1.08 to 2.22), high 1.29 (95% CI 1.04 to 1.59), and medium 1.16 (95% CI 0.97 to 1.38). Among 3,202 trauma nonarrests, survival was not associated with rescuer tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.84 (95% CI 0.89 to 3.81), high 1.25 (95% CI 0.85 to 1.85), and medium 0.92 (95% CI 0.67 to 1.26). Conclusion Rescuer procedural experience is associated with improved patient survival after out-of-hospital tracheal intubation of cardiac arrest and medical nonarrest patients. Rescuer procedural experience is not associated with patient survival after out-of-hospital tracheal intubation of trauma nonarrest patients.

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“…15,16 Yet many in the emergency medical services (EMS) community still believe that ETI should continue in the prehospital setting and consider it an essential paramedic skill. 17 Out-of-hospital cardiac arrest patients comprise the majority of paramedic intubation attempts and also have the highest prehospital intubation success rates. 18 In the prehospital setting, the practice of early intubation still frequently occurs in OOHCA management.…”

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confidence: 99%

The Association Between Prehospital Endotracheal Intubation Attempts and Survival to Hospital Discharge Among Out‐of‐hospital Cardiac Arrest Patients

Studnek

Thestrup

Vandeventer

et al. 2010

Academic Emergency Medicine

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Objectives: The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA.Methods: This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts.Results: There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt. Conclusions:Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations.ACADEMIC EMERGENCY MEDICINE 2010; 17:918-925 ª

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Paramedic Perceptions of Challenges in Out-of-Hospital Endotracheal Intubation

Abstract: Paramedics and EMS physicians attribute paramedic ETI performance to a myriad of factors involving EMS education, organization, oversight, retention, and professionalism. Efforts to improve ETI must include strategies to address multiple aspects of EMS operations and culture.

Cited by 19 publications

References 22 publications

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes

The Association Between Prehospital Endotracheal Intubation Attempts and Survival to Hospital Discharge Among Out‐of‐hospital Cardiac Arrest Patients

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