Intubation Success in Critical Care Transport: A Multicenter Study

Introduction: Tracheal intubation (TI) is a lifesaving critical care skill. Failed TI attempts, however, can harm patients. Critical care transport (CCT) teams function as the first point of critical care contact for patients being transported to tertiary medical centers for specialized surgical, medical, and trauma care. The Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement Collaborative uses a quality metric database to track CCT quality metric performance, including TI. We sought to describe TI among GAMUT participants with the hypothesis that CCT would perform better than other prehospital TI reports and similarly to hospital TI success. Methods: The GAMUT Database is a global, voluntary database for tracking consensus quality metric performance among CCT programs performing neonatal, pediatric, and adult transports. The TI-specific quality metrics are “first attempt TI success” and “definitive airway sans hypoxia/hypotension on first attempt (DASH-1A).” The 2015 GAMUT Database was queried and analysis included patient age, program type, and intubation success rate. Analysis included simple statistics and Pearson chi-square with Bonferroni-adjusted post hoc z tests (significance = p < 0.05 via two-sided testing). Results: Overall, 85,704 patient contacts (neonatal n [%] = 12,664 [14.8%], pediatric n [%] = 28,992 [33.8%], adult n [%] = 44,048 [51.4%]) were included, with 4,036 (4.7%) TI attempts. First attempt TI success was lowest in neonates (59.3%, 617 attempts), better in pediatrics (81.7%, 519 attempts), and best in adults (87%, 2900 attempts), p < 0.001. Adult-focused CCT teams had higher overall first attempt TI success versus pediatric- and neonatal-focused teams (86.9% vs. 63.5%, p < 0.001) and also in pediatric first attempt TI success (86.5% vs. 75.3%, p < 0.001). DASH-1A rates were lower across all patient types (neonatal = 51.9%, pediatric = 74.3%, adult = 79.8%). Conclusions: CCT TI is not uncommon, and rates of TI and DASH-1A success are higher in adult patients and adult-focused CCT teams. TI success rates are higher in CCT than other prehospital settings, but lower than in-hospital success TI rates. Identifying factors influencing TI success among high performers should influence best practice strategies for TI.     

持续质量改进提高人工呼吸道患者的沟通满意度

目的 加强人工呼吸道患者有效沟通途径,提高患者沟通满意度,体现ICU患者的人文关怀。方法 将持续质量改进原则应用于加强危重患者的有效沟通中,找出与人工呼吸道患者沟通中存在的问题,制定计划、实施方案、评估效果、总结归纳、发现新问题。结果 经过质量改进循环后,2006年我科患者沟通满意度比2005年提高了30%,非计划拔管的发生率从5.9%下降到1.8%。结论 持续质量改进是一个不断完善的过程,遵循护理质量持续改进原则有利于护理质量的优效管理。     

A Meta-Analysis of Prehospital Airway Control Techniques Part I: Orotracheal and Nasotracheal Intubation Success Rates

Abstract

Background. Airway management is a key component of prehospital care for seriously ill and injured patients. Although endotracheal intubation has been a commonly performed prehospital procedure for nearly three decades, the safety and efficacy profile of prehospital intubation has been challenged in the last decade. Reported intubation success rates vary widely, and established benchmarks are lacking. Objective. We sought to determine pooled estimates for oral endotracheal intubation (OETI) and nasotracheal intubation (NTI) placement success rates through a meta-analysis of the literature. Methods. We performed a systematic literature search for all English-language articles reporting placement success rates for prehospital intubation. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique, including drug-facilitated intubation (DFI) and rapid-sequence intubation (RSI), were calculated using a random-effects model. Historical trends were evaluated using meta-regression. Results. Of 2,005 identified titles reviewed, 117 studies addressed OETI and 23 addressed NTI, encompassing a total of 57,132 prehospital patients. There was substantial interrater reliability in the review process (kappa = 0.81). The pooled estimates (and 95% confidence intervals [CIs]) for intervention success for nonphysician clinicians were as follows: overall non-RSI/non-DFI OETI success rate: 86.3% (82.6%–89.4%); OETI for non–cardiac arrest patients: 69.8% (50.9%–83.8%); DFI 86.8% (80.2%–91.4%); and RSI 96.7% (94.7%–98.0%). For pediatric patients, the paramedic OETI success rate was 83.2% (55.2%–95.2%). The overall NTI success rate for nonphysician clinicians was 75.9% (65.9%–83.7%). The historical trend of OETI reflects a 0.49% decline in success rates per year. Conclusions. We provide pooled estimates of placement success rates for prehospital airway interventions. For some patient and clinician characteristics, OETI has relatively low success rates. For nonarrest patients, DFI and RSI appear to increase success rates. Across all clinicians, NTI has a low rate of success, raising questions about the safety and efficacy of this procedure.     

Location of Airway Management in Air Medical Transport

Background. Prehospital providers are constantly challenged with the task of managing airways in unpredictable andoften inhospitable environments. Air medical transport (AMT) crews must be prepared to work in restrictive spaces with limited resources while in the aircraft. This study examines flight crew success rate andcircumstances surrounding airway management in different locations. Methods. This was a retrospective analysis of intubations performed by a university-based air medical transport team from January 1, 1995, to May 31, 2007. Patient records andprospectively gathered airway management quality assurance data were reviewed for location of intubation, patient characteristics, andsuccess rates. Success was defined as placing a cuffed tube in the trachea nonsurgically. Results. Nine hundred thirty-eight patients required 939 advanced airway management procedures, and936 cases had information sufficient for analysis. Six hundred twenty-seven (67%) of these intubations took place on scene, 235 (25.1%) at the referring hospital, 67 en-route (7.2%), andseven (0.7%) at the receiving hospital. The overall intubation success rate was 96% andthe highest rate was for hospital intubations (98.8%), followed by scene (94.9%) anden-route (89.6%) airway encounters. Intubation success was more likely in the hospital setting (odds ratio [OR] = 8.7, 95% confidence interval [CI] 2.2–35.0, p = 0.002] andon the scene [OR = 2.3, 95% CI 0.95–5.7, p = 0.065] compared with those en-route. Unanticipated patient deterioration was noted as the most common reason for in-flight airway management. Type of aircraft was not significantly associated with intubation success (p = 0.132). Conclusions. Airway management was performed with a high success rate in a variety of locations andpatient characteristics by our air medical crew. When in the hospital environment, flight crew success rates were comparable to those of other emergency personnel. Caution should be used, however, when considering intubating in-flight because of slightly lower success rates.     

Flight crew airway management in four settings: A six-year review

Objective. To analyze flight crew airway management in four different settings (in flight, at trauma scenes, in ambulance, and in referring hospitals) and in two different aircraft used by the same helicopter EMS (HEMS) service. The null hypothesis was that there was no association between practice setting, or aircraft, and airway practices or success rate. Methods. This retrospective study analyzed all patients in whom advanced airway management was attempted by the HEMS service during the study period October 1991 through October 1997. Data used were from flight records of Boston MedFlight Critical Care Transport Service, which uses a nurse/ paramedic crew and had a paralytic-assisted intubation protocol in place. Data were analyzed with chi-square and Fisher's exact testing, risk ratio analysis, and logistic regression. Results. Advanced airway management was attempted in 722 patients, with an airway placed in 705 (97.8%). Intubation success was unrelated to site of airway management (p = 0.14), but patients were more likely to have intubation attempted prior to flight (as opposed to in flight) if the crew were in the AS365N2 Dauphin as compared with the BK-117 (p < 0.0001). In addition, patients were 0.77 times as likely (95% confidence interval, 0.68–0.88) to receive paralytic-facilitated intubation if airway management occurred in the hospital setting as compared with other sites. Conclusions. While HEMS crew airway management success rates are equally high in all practice settings, airway management decision making and practice appear to be significantly influenced by practice setting and aircraft type. These data support contentions that nonphysician HEMS crews can effectively manage airways in a variety of circumstances.     

持续质量改进在放射诊断科护理管理中的应用

目的 探讨持续质量改进在放射诊断科护理管理中的应用方法及效果.方法 2010年底,第三军医大学大坪医院野战外科研究所放射诊断科开始对护理管理进行持续质量改进,具体措施包括健全放射诊断科护理质量层级岗位管理模式;明确岗位定义和任职资格;完善质量控制的制度、指标、标准、操作规范和流程,确定质量控制形式,并将质量控制与绩效考核相结合,形成符合放射诊断科护理发展的质量控制机制等.结果 2012年,放射科实施持续质量改进后,与实施前(2010年)比较,护理质量检查的相关指标均有明显改善(均P＜0.01).结论 持续质量改进应用于放射诊断科护理管理中能够全面提升护理质量,对推动放射科护理工作发展具有重要的指导意义.     

Video Laryngoscopic Techniques Associated with Intubation Success in a Helicopter Emergency Medical Service System

Objectives. Video laryngoscopy (VL) is a technical adjunct to facilitate endotracheal intubation (ETI). VL also provides objective data for training and quality improvement, allowing evaluation of the technique and airway conditions during ETI. Previous studies of factors associated with ETI success or failure are limited by insufficient nomenclature, individual recall bias and self-report. We tested whether the covariates in prehospital VL recorded data were associated with ETI success. We also measured association between time and clinical variables. Methods. Retrospective review was conducted in a non-physician staffed helicopter emergency medical service system. ETI was typically performed using sedation and neuromuscular-blockade under protocolized orders. We obtained process and outcome variables from digitally recorded VL data. Patient characteristics data were also obtained from the emergency medical service record and linked to the VL recorded data. The primary outcome was to identify VL covariates associated with successful ETI attempts. Results. Among 304 VL recorded ETI attempts in 268 patients, ETI succeeded for 244 attempts and failed for 60 attempts (first-pass success rate, 82% and overall success rate, 94%). Laryngoscope blade tip usually moved from a shallow position in the oropharynx to the vallecula. In the multivariable logistic regression analysis, attempt time (p = 0.02; odds ratio [OR] 0.99), Cormack-Lehane view (p < 0.001; OR 0.23), bodily fluids obstructing the view (p = 0.01; OR 0.29), and VL equipment failure (p < 0.001; OR 0.14) were negatively associated with successful attempts. Bodily fluids obstructing the view (p < 0.001; hazard ratio [HR] 0.51), VL equipment failure (p = 0.003; HR 0.42), shallow placement of blade tip within 4 seconds (p < 0.001; HR 0.40), number of forward movements (p < 0.001; HR 0.84), trauma (p = 0.04; HR 0.65), and neurological diagnosis (p = 0.04; HR 0.60) were associated with longer ETI attempt time. Conclusions. Bodily fluids obstructing the view, equipment problems, higher Cormack-Lehane view, and longer ETI attempt time were negatively associated with successful ETI attempts. Initially shallow blade tip position may associate with longer ETI time. VL is useful for measuring and describing multiple factors of ETI and can provide valuable data.     

持续质量改进在普外科PICC置管中的应用效果

目的探讨持续质量改进在PICC培训及安全管理中的效果。方法在PICC应用过程中,运用持续质量改进方法进行管理,包括加强PICC知识与维护技能的培训、制定PICC管理流程、规范PICC置管后日常护理行为等。结果实施持续质量改进后,科室护士PICC知识、技能考核的合格率均为100%,置管成功率为99.1%,静脉炎及导管堵塞的发生率分别为1.8%及0.9%,与改进前差异均有统计学意义(均P<0.01)。结论将持续质量改进应用于PICC培训及安全管理中,规范了PICC管理流程及护理人员的日常护理行为,降低了并发症的发生率,切实提高了护理质量。     

Program Accreditation Effect on Paramedic Credentialing Examination Success Rate

Objectives. Program accreditation is used to ensure the delivery of quality education andtraining for allied health providers. However, accreditation is not mandated for paramedic education programs. This study examined if there is a relationship between completion of an accredited paramedic education program andachieving a passing score on the National Registry Paramedic Certification Examination. Methods. We used data from the National Registry Paramedic Certification Examination for calendar year 2002. Successful completion (passing) of the examination was defined as correctly answering a minimum of 126 out of 180 (70%) of the questions andmeeting or exceeding the individual subtest passing scores. Accredited paramedic training programs were certified by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) on or before January 1, 2002. Candidates reported demographic characteristics including age, gender, self-reported race andethnicity, education, andemployer type. We examined the relationship between passing the examination andattendance at an accredited paramedic training program. Results. A total of 12,773 students completed the examination. Students who attended an accredited program were more likely to pass the examination (OR = 1.65, 95% CI: 1.51–1.81). Attendance at an accredited training program was independently associated with passing the examination (OR = 1.58, 95% CI = 1.43–1.74) even after accounting for confounding demographic factors. Conclusion. Students who attended an accredited paramedic program were more likely to achieve a passing score on a national paramedic credentialing examination. Additional studies are needed to identify the aspects of program accreditation that lead to improved examination success.     

Delayed Sequence Intubation by Intensive Care Flight Paramedics in Victoria,Australia

Objective: Delayed sequence intubation (DSI) involves the administration of ketamine to facilitate adequate preoxygenation in the agitated patient. DSI was introduced into the Clinical Practice Guideline for Intensive Care Flight Paramedics in Victoria in late 2013. We aimed to describe the clinical characteristics of patients receiving DSI. Methods: A retrospective analysis was undertaken of patients who received DSI between January 1, 2014, and December 31, 2016, during both primary response and retrieval missions. Patients' clinical characteristics, DSI success rates, and complications were determined from electronic patient care records. Results: Forty patients received DSI during the study period. Of these, 32 were intubated to manage traumatic injury and the remaining 8 were intubated for medical reasons. On arrival of the first road ambulance, median oxygen saturation was 96.5%, and immediately prior to DSI the median was 98.0%. One patient had a period of self-limiting apnea (< 15 seconds) following ketamine administration. Oxygen saturation was either maintained or increased prior to laryngoscopy in all patients. Post-intubation, one patient experienced bradycardia (heart rate < 60 beats per minute), two patients had a systolic blood pressure drop of > 20 mm Hg, one patient experienced an increase in heart rate of > 20 beats per minute, and two patients had transient oxygen desaturation (< 85%). No patients experienced cardiac arrest or required surgical airway intervention. All patients were successfully intubated. After DSI, the median oxygen saturation was 100%. Conclusions: DSI provides a reasonably safe and effective approach for intensive care flight paramedics in the preoxygenation of agitated, hypoxic patients in order to decrease the risk of peri-intubation desaturation and related hypoxic injury     

Continuous Quality Improvement Reduces Length of Stay for Fast-track Patients in an Emergency Department

Objective: To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illness/injury in an ED.
Methods: A CQI team documented the process of fast-track (FT) patient flow and prioritized the causes of delay. In Phase I, two solutions were implemented. In this Phase II of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full-time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis of variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre-Phase II intervention 48-hour periods and one post-Phase II intervention 48-hour period were analyzed.
Results: Before the Phase I changes, the mean ± SD LOS was 92 ± 46 min. After the Phase I changes, the LOS was 67 ± 31 min. After the Phase II changes, this was reduced to 57 ± 34 min (p < 0. 05).
Conclusion: The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients.     

A Comparison of Rapid-Sequence Intubation andEtomidate-Only Intubation in the Prehospital Air Medical Setting

Objectives. To compare laryngoscopy conditions produced by etomidate-only intubation (EOI) with those produced by rapid-sequence intubation (RSI) in the prehospital air medical setting. Methods. A prospective crossover trial design used two helicopters staffed by the same flight paramedics andnurses. Each aircraft used an EOI protocol (0.3 mg/kg) for six months. An RSI protocol using the same dose of etomidate plus succinylcholine (1.5 mg/kg) was used for the alternate six months. Laryngoscopy conditions were graded by three scales: 1) a formal Laryngoscopy Grading Scale (LGS), 2) the Percentage of Glottic Opening (POGO) score, and3) subjective overall intubation difficulty using a Likert scale of 1 (very easy) to 5 (very difficult). Orotracheal intubation success was also recorded. Results. Forty-nine patients were intubated using the EOI (n = 24) andRSI (n = 25) protocols. Mean age was 38 years, 76% were male, and90% were intubated for trauma. Fifteen (63%) of the 24 EOI patients required additional etomidate (n = 3) or RSI (n = 12) to allow intubation, while one (4%) of the 25 RSI patients required additional medication dosing (p < 0.0001). Laryngoscopy conditions were assessed for all patients. Good or acceptable conditions as assessed by the LGS were seen in 79% of RSI patients and13% of EOI patients (p < 0.0001). Mean rates of POGO visualization were 60% with RSI and12% with EOI (p < 0.0001). Mean global intubation difficulty scores were 3.0 (moderate) with RSI and4.7 (difficult to very difficult) with EOI (p < 0.0001). Ninety-two percent of the patients undergoing RSI and25% of the EOI patients were successfully orotracheally intubated (p < 0.0001). Conclusions. Patients receiving RSI had better laryngoscopy conditions andwere easier to intubate than patients receiving EOI. Intubation success rate was higher with RSI.     

持续质量改进在预防和控制医院感染中的应用

目的探讨持续质量改进在预防和控制医院感染中的应用及其效果。方法对2009-2011年解放军第163医院的感染情况进行分析,持续质量改进,制定实施方案,评价效果。结果经过持续质量改进,医院感染发生率由2009年的4.30%下降至2011年的2.49%,环境卫生学监测合格率由2009年的97.26%提高至2011年的99.01%。结论持续质量改进有利于促进预防和控制医院感染良性循环模式的建立,对预防和控制医院感染有重要的作用。     

Prehospital Intubation is Associated with Favorable Outcomes and Lower Mortality in ProTECT III

Objective: Traumatic brain injury (TBI) causes more than 2.5 million emergency department visits, hospitalizations, or deaths annually. Prehospital endotracheal intubation has been associated with poor outcomes in patients with TBI in several retrospective observational studies. We evaluated the relationship between prehospital intubation, functional outcomes, and mortality using high quality data on clinical practice collected prospectively during a randomized multicenter clinical trial. Methods: ProTECT III was a multicenter randomized, double-blind, placebo-controlled trial of early administration of progesterone in 882 patients with acute moderate to severe nonpenetrating TBI. Patients were excluded if they had an index GCS of 3 and nonreactive pupils, those with withdrawal of life support on arrival, and if they had documented prolonged hypotension and/or hypoxia. Prehospital intubation was performed as per local clinical protocol in each participating EMS system. Models for favorable outcome and mortality included prehospital intubation, method of transport, index GCS, age, race, and ethnicity as independent variables. Significance was set at α = 0.05. Favorable outcome was defined by a stratified dichotomy of the GOS-E scores in which the definition of favorable outcome depended on the severity of the initial injury. Results: Favorable outcome was more frequent in the 349 subjects with prehospital intubation (57.3%) than in the other 533 patients (46.0%, p = 0.003). Mortality was also lower in the prehospital intubation group (13.8% v. 19.5%, p = 0.03). Logistic regression analysis of prehospital intubation and mortality, adjusted for index GCS, showed that odds of dying for those with prehospital intubation were 47% lower than for those that were not intubated (OR = 0.53, 95% CI = 0.36–0.78). 279 patients with prehospital intubation were transported by air. Modeling transport method and mortality, adjusted for index GCS, showed increased odds of dying in those transported by ground compared to those transported by air (OR = 2.10, 95% CI = 1.40–3.15). Decreased odds of dying trended among those with prehospital intubation adjusted for transport method, index GCS score at randomization, age, and race/ethnicity (OR = 0.70, 95% CI = 0.37–1.31). Conclusions: In this study that excluded moribund patients, prehospital intubation was performed primarily in patients transported by air. Prehospital intubation and air medical transport together were associated with favorable outcomes and lower mortality. Prehospital intubation was not associated with increased morbidity or mortality regardless of transport method or severity of injury.     

持续质量改进在肺癌患者急救护理中的应用

目的探讨持续质量改进理论在肺癌患者急救护理中的应用及效果。方法应用持续质量改进理论对肺癌患者急救护理中的问题进行总结分析,制定加强基础护理操作的培训、组织深入的理论知识学习、开展回顾性情景演练和进行阶段性讲评等改进措施,并以护理质量、护士急救考核成绩和护士认可度等指标评价持续质量改进的临床效果。结果实施持续质量改进管理方法后,急救护理质量、护士急救考核成绩明显高于实施前,全体护士认为持续质量改进提高了急救技能和协作水平,同时还增强了人文意识和风险意识。结论持续质量改进增强了护士的职业技能,促进了肺癌急救护理质量的提升。     

持续质量改进在手术室护理质量管理中的实施及效果评价

目的：调查手术室实施持续质量改进（continuous quality improvement,CQI）对手术室护理工作质量、工作效率和医生、患者满意度的影响。方法：成立科室质量控制小组,全科护理人员均为责任人。根据手术室质量管理中存在的问题确立改进目标,实施CQI。质控小组定期监测及发放问卷调查并比较实施CQI前后手术室工作质量、工作效率及医生和患者的满意度。结果：实施CQI后,手术室的术前用药准备、术前平面清洁、术后整理、药品按序摆放、物品定位放置、仪器完好、器械清洗合格各项指标均较实施CQI前改善;手术等待时间缩短,手术总台次增加;医生和患者的满意度提高。结论：通过实施CI,规范了护士的行为,提高了手术室的工作质量和工作效率,增加了医生和患者的满意度。     

观摩式监测法在医院护理质量持续改进中的应用效果

目的探讨观摩式监测法在护理质量持续改进中的应用效果。方法 2010年1月,解放军第88医院将以帮助科室解决问题为主要目标的观摩式监测法应用于护理环节质量控制中,与实施传统的现场考核法时护理人员的满意度及护理质量合格率作比较。结果护理人员对实施现场观摩式监测法的总体满意度评分为(2.5±0.50)分,满意度较高;病区自行监测护理质量合格率由实施现场考核法时的95.32%上升为实施现场观摩式监测法时的98.63%,差异有统计学意义(χ2=-8.66,P<0.01);医院监测护理质量合格率由实施现场考核法时的95.34%上升为实施现场观摩式监测法时的98.58%,差异有统计学意义(χ2=-8.52,P<0.01)。结论观摩式监测法的实施突出了护士长在环节质量监测中的主导地位,确定了以帮助解决问题为目标的监测思路,淡化了护理质量监测中的问责意识,强化了全员参与意识,有利于促进护理质量的不断提升。     

Performance of Endotracheal Intubation and Rescue Techniques by Emergency Services Personnel in an Air Medical Service

Background. Literature spanning the last two decades has identified potential harm associated with out-of-hospital endotracheal intubation performed by ground paramedics. Previous researchers have reported intubation success rates of 66% to 97% in the air medical setting. Objective. To examine the success of endotracheal intubation and rescue techniques performed by air medical personnel during the first eight years of operation of the air ambulance service. Methods. This study was a retrospective survey of health records utilizing data from LifeFlight of Maine's airway procedure quality review database, covering the first eight years of system encounters. Results. During the study period, 369 intubation encounters occurred. Rapid-sequence intubation medications were administered in 345 (93.5%) cases. Flight personnel successfully performed endotracheal intubation in 340 (92.1%) encounters. Unsuccessful intubations were managed with an alternative definitive airway, rescue airway, or bag–valve–mask. Laryngeal mask airway (n = 11) was the most commonly used rescue airway device. Conclusions. During the first eight years of operation of this air medical transport system, flight personnel were able to successfully perform endotracheal intubation in 92.1% of cases.     

持续质量改进在多重耐药菌感染控制中的应用

目的探讨持续质量改进在多重耐药菌感染控制中的应用效果。方法通过调查,针对存在的问题,实施质量改进措施,比较持续质量改进前后,多重耐药菌感染患者医院感染防控措施落实情况、多重耐药菌分离率及多重耐药菌医院感染发生比。结果持续质量改进后,临床科室各项感染控制措施落实情况较持续质量改进前明显好转(P0.05),差异有统计学意义。结论实施持续质量改进有效提高了临床科室对院感防控措施的执行力,降低了多重耐药菌的医院感染发生率。