Airway/original research
Techniques, Success, and Adverse Events of Emergency Department Adult Intubations

https://doi.org/10.1016/j.annemergmed.2014.10.036Get rights and content

Study objective

We describe the operators, techniques, success, and adverse event rates of adult emergency department (ED) intubation through multicenter prospective surveillance.

Methods

Eighteen EDs in the United States, Canada, and Australia recorded intubation data onto a Web-based data collection tool, with a greater than or equal to 90% reporting compliance requirement. We report proportions with binomial 95% confidence intervals (CIs) and regression, with year as the dependent variable, to model change over time.

Results

Of 18 participating centers, 5 were excluded for failing to meet compliance standards. From the remaining 13 centers, we report data on 17,583 emergency intubations of patients aged 15 years or older from 2002 to 2012. Indications were medical in 65% of patients and trauma in 31%. Rapid sequence intubation was the first method attempted in 85% of encounters. Emergency physicians managed 95% of intubations and most (79%) were physician trainees. Direct laryngoscopy was used in 84% of first attempts. Video laryngoscopy use increased from less than 1% in the first 3 years to 27% in the last 3 years (risk difference 27%; 95% CI 25% to 28%; mean odds ratio increase per year [ie, slope] 1.7; 95% CI 1.6 to 1.8). Etomidate was used in 91% and succinylcholine in 75% of rapid sequence intubations. Among rapid sequence intubations, rocuronium use increased from 8.2% in the first 3 years to 42% in the last 3 years (mean odds ratio increase per year 1.3; 95% CI 1.3 to 1.3). The first-attempt intubation success rate was 83% (95% CI 83% to 84%) and was higher in the last 3 years than in the first 3 (86% versus 80%; risk difference 6.2%; 95% CI 4.2% to 7.8%). The airway was successfully secured in 99.4% of encounters (95% CI 99.3% to 99.6%).

Conclusion

In the EDs we studied, emergency intubation has a high and increasing success rate. Both drug and device selection evolved significantly during the study period.

Introduction

By 2002, the majority of emergency department (ED) intubations were performed by emergency physicians, predominantly using rapid sequence intubation.1, 2, 3 Reports of intubation success and events are sparse, and only one previous study reported results from intubations occurring across multiple centers through 2002.1 Since then, the practice of emergency intubation has been influenced by an array of new devices and techniques. Rates of adoption of these new approaches and related outcomes are relevant to quality of care and patient safety. Debate has ensued about the merits of new devices, principally video laryngoscopes, and the safety and desirability of various induction and neuromuscular-blocking agents.4, 5, 6, 7, 8, 9, 10, 11, 12 There are very few ED-based, multicenter studies that can provide insight about techniques used, expected success and adverse event rates, and the evolution of airway management over time.1, 3, 13

Editor’s Capsule Summary

What is already known on this topic

Airway management is an important component of emergency medicine practice. Changes in this practice over time have not been systematically evaluated on a large scale.

What question this study addressed

This prospective, multicenter, international registry of 17,583 emergency department (ED) airways managed in 13 mostly academic EDs tracked indications, techniques, pharmacologic adjuncts, and adverse events from 2002 to 2012.

What this study adds to our knowledge

Most airways were managed with direct laryngoscopy and succinylcholine, though the use of video laryngoscopy and rocuronium has increased recently. Despite this, first-pass success remained below 88% in all years.

How this is relevant to clinical practice

This study captures trends in airway management in a large group of patients at 13 sites and helps practitioners identify opportunities to modify their own practice.

For a high-risk medical procedure that is known to be evolving so rapidly, ongoing surveillance is essential to define current practice and identify trends in intubation techniques and outcomes. Such surveillance can provide benchmarks for quality outcomes, including success and adverse event rates. Although single-center reports are helpful, generalizability is limited. Intubation is a lifesaving procedure with little room for error, and recent studies have shown that adverse events are more likely with increased numbers of intubation attempts.11, 14, 15 Therefore, monitoring trends in clinical practice and intubation performance is important for patient safety and allows centers to compare their own practices and performance with those of a large, multicenter population.

We sought to characterize ED intubation practices spanning a decade of experience to analyze performance attributes and identify evolving trends.

Section snippets

Study Design

This is an analysis of a prospective multicenter registry of ED intubations, approved by the institutional review boards of all participating centers.

Setting

The National Emergency Airway Registry is an international network of academic and community hospitals. Each center had a site investigator who was responsible for ensuring compliance, defined as data entry on 90% or more of ED intubations, confirmed by comparison of captured patient data with institutional coding for intubation procedures. Center

Results

Of 18 reporting sites, 5 were excluded for failing to maintain consistant compliance standards. In the 13 compliant sites, 19,629 unique encounters were recorded from July 2002 through December 2012; 17,583 adult airway encounters met inclusion criteria for analysis. There were 11,488 (65%) medical and 5,451 (31%) trauma encounters. There were 644 (3.7%) free-text entries classified as “other.” The indications for intubation are reported in Table 1.

Emergency physicians were the primary

Limitations

Our study has several important limitations. First, self-reporting is subject to the possibility of bias, including selective reporting of intubation attempts, failures, and adverse events. Our rate of adverse events is low compared with that of previous literature and may represent underreporting.11, 14 This may bias our results toward better overall airway management performance. Active compliance reporting and monitoring limit this possibility, and we have no indication that intentional

Discussion

We report on practices and trends among 17,583 adult ED intubations from 13 centers. Emergency physicians managed 95% of all encounters, higher than what has historically been reported.1, 2 This provides continued evidence that emergency physicians are the principal point of contact for critically ill and injured patients requiring airway management and highlights the importance of airway management education and research to modern emergency care. That most operators were emergency medicine

References (27)

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Please see page 364 for the Editor’s Capsule Summary of this article.

Supervising editor: Richard M. Levitan, MD

Author contributions: CAB monitored data collection and compliance, authored the article, and made final editorial decisions. AEB contributed to study design, data monitoring, and article development. DJP analyzed the data and helped draft the article. RMW conceived of and oversaw the project, and helped draft the article. CAB takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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