Groombridge Christopher, Maini Amit, Olaussen Alexander, Kim Yen, Fitzgerald Mark, Mitra Biswadev, Smit De Villiers
National Trauma Research Institute, Melbourne, Victoria, Australia
Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.
Emerg Med J. 2020 Sep;37(9):576-580. doi: 10.1136/emermed-2019-208935. Epub 2020 Jun 17.
Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI.
This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period.
There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)).
This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.
气管插管（ETI）是急诊科常见但潜在风险较高的操作。研究表明，气管插管需要多次尝试会增加不良事件的发生几率，因此应确定提高首次尝试成功率的干预措施，以提高急诊科气管插管操作的安全性。我们引入并研究了一系列有针对性的气道干预措施对气管插管首次尝试成功率和相关不良事件的影响。
这项前瞻性、干预性队列研究在澳大利亚一家主要创伤中心进行，为期两年。研究开始时建立了一个在线气道登记系统，以收集所有插管相关信息。6个月后，我们引入了一系列措施，包括每月审核、每月气道管理教育和一份气道管理检查表。采用时间序列分析模型，将标准操作（即前6个月）与干预后时期进行比较。
共有526例患者，干预组369例，干预前对照组157例。共进行了573次插管尝试。干预前组和干预后组的首次尝试成功率有显著提高（88.5%对94.6%，相对风险1.07；95%可信区间1.00至1.14，p = .014）。引入干预措施后，首次尝试成功率显著提高，第一个月提高了13.4%（p = .006），随后每月趋势显著增加（相对于干预前趋势）1.71%（p < .001）。干预前和干预后的不良事件发生率相似（低氧血症8.3%对8.9%（p = .81）；低血压8.3%对7.0%（p = .62）；任何并发症27.4%对23.6%（p = .35））。
这一系列气道管理措施与气管插管首次尝试成功率的显著提高相关。基于专用气道登记系统审核的定期教育计划，结合围手术期检查表的引入，是一项值得开展的急诊科质量改进措施。
