Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

Abstract

IntroductionPre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.MethodsWe conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.ResultsFrom 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).ConclusionsThis comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.

Performance of intubation with 4 different airway devices by unskilled rescuers: manikin study

“…Based on these findings, it may be difficult to acquire and maintain intubation skills with the MCL. Some previous studies have reported analogous conclusions to these [24][25][26][27].…”

Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review

“…[144][145][146][147][148][149][150] Further, prehospital intubation is not always available and the ability to perform this procedure safely varies among prehospital EMS personnel, with physicians having the highest success rates. [144][145][146][147][148][149][150][151] Prioritizing advanced airway management and spinal immobilization may also delay release and rescue procedures as well as make the trauma examination more difficult, both at the scene, during transport, and at admittance. 13,96,152 Delayed definitive care can be detrimental for patients with non-neurological critical injuries, and importantly, also lead to neurological progression, because spinal injuries are often neurologically unstable, but biomechanically stable in the acute phase.…”

Indications and results of emergency surgical airways performed by a physician-staffed helicopter emergency service

“…Therefore, advanced airway management is essential. Success rates in prehospital airway management vary, and a meta-analysis of prehospital care providers comparing paramedic and physician ETI revealed significant differences in success rates in favour of physicianstaffed services [9,10]. The ETI success rate of physicians in our group was 98.4%.…”