Original contribution
Emergency Airway Management: A Multi-Center Report of 8937 Emergency Department Intubations

https://doi.org/10.1016/j.jemermed.2010.02.024Get rights and content

Abstract

Objective: Emergency department (ED) intubation personnel and practices have changed dramatically in recent decades, but have been described only in single-center studies. We sought to better describe ED intubations by using a multi-center registry. Methods: We established a multi-center registry and initiated surveillance of a longitudinal, prospective convenience sample of intubations at 31 EDs. Clinicians filled out a data form after each intubation. Our main outcome measures were descriptive. We characterized indications, methods, medications, success rates, intubator characteristics, and associated event rates. We report proportions with 95% confidence intervals and chi-squared testing; p-values < 0.05 were considered significant. Results: There were 8937 encounters recorded from September 1997 to June 2002. The intubation was performed for medical emergencies in 5951 encounters (67%) and for trauma in 2337 (26%); 649 (7%) did not have a recorded mechanism or indication. Rapid sequence intubation was the initial method chosen in 6138 of 8937 intubations (69%) and in 84% of encounters that involved any intubation medication. The first method chosen was successful in 95%, and intubation was ultimately successful in 99%. Emergency physicians performed 87% of intubations and anesthesiologists 3%. Several other specialties comprised the remaining 10%. One or more associated events were reported in 779 (9%) encounters, with an average of 12 per 100 encounters. No medication errors were reported in 6138 rapid sequence intubations. Surgical airways were performed in 0.84% of all cases and 1.7% of trauma cases. Conclusion: Emergency physicians perform the vast majority of ED intubations. ED intubation is performed more commonly for medical than traumatic indications. Rapid sequence intubation is the most common method of ED intubation.

Introduction

The advent of emergency medicine as a specialty has led to advances in emergency airway management. Residency training in emergency medicine emphasizes airway management, including use of rapid sequence intubation (RSI), defined as intubation after rapid induction and paralysis (1, 2). Several previous studies, mostly with small samples, have reported intubation success rates within single institutions, but comprehensive large multi-center studies are lacking (3, 4, 5, 6, 7).

Although intubation frequently is performed in emergency departments (EDs) today, little is known about why and how ED patients are intubated, and by whom. Surveillance of critical emergency procedures is essential for reasons of public health, policy, and clinical practice development. Our goal in this report is to describe emergency intubation indications, methods used, operator characteristics, and adverse event rates using a multi-center registry model.

Section snippets

Study Design

This was a prospective observational multi-center data registry, with all data collection planned a priori. The Institutional Review Board of each participating center approved the protocol prospectively.

Study Setting and Population

We formed a network of 31 centers, both academic and community, that collected data from September 1997–June 2002 (Appendix). All ED patients with attempted endotracheal intubation were eligible for inclusion. We conducted an audit of one center to estimate reporting compliance, though we did

Results

The final database included 8937 encounters. Table 1 shows the primary indications for intubation. Table 2 shows the initial method of airway management for each subject. RSI was the initial method chosen in 6138 of 8937 intubations (69%) and in 84% of encounters that involved any intubation medication. Induction agents or sedatives, without neuromuscular blockade, were chosen in 571 encounters (6.4%). Oral intubation without any medication was used in 1659 encounters (19%). Nasal intubation

Discussion

We present data describing 8937 intubations in 31 EDs. This is the largest multi-center sample of ED intubations yet reported. Even allowing for the observational nature of this study, certain conclusions seem valid and unlikely to be contradicted by other study designs. These conclusions apply to centers comparable to those included in our registry (i.e., mostly academic medical centers).

First, about twice as many ED intubations are performed for medical emergencies as for trauma. In our

Conclusion

We have created a multi-center network of EDs for intubation surveillance, which can serve two purposes.

First, we have provided fundamental descriptive data, which can inform future studies and serve as a reference for evaluation of performance in comparable departments. We have shown that most ED intubations are performed for medical indications, most commonly cardiac arrest, overdose, congestive heart failure, and coma, together accounting for 33% of all intubations. We have shown that, in

Acknowledgments

We are grateful to Richard Kulkarni, Michael Filbin, Mark Sagarin, Evelyn Wong, Peter Pang, Yi-Mei Chng, and all of the residents of the Brigham and Women's Hospital/Massachusetts General Hospital Harvard Affiliated Emergency Medicine Residency, to Richard E. Wolfe, md and Robert Vissers, md for their outstanding contributions during the early days of NEAR, to Dawn DeCosta and Gabrielle Billeter, to the various members of our Research and Publications Committee, and to our many investigators

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See Appendix for listing of NEAR II investigators. RMW conceived the project and served as principal investigator, designed the data form and database management system, designed the study, and was primary author and final editor of the manuscript. CAB oversaw compliance for all sites within the study, served as primary site investigator at the Brigham and Women's site, served on the coordinating committee, oversaw data management and retrieval, and was responsible for the integrity of the database. AEB served as the site investigator at the largest enrolling center, performed sub-analyses, and participated in the writing and editing of the revised manuscript. DJP imported, merged, and organized the data, performed all statistical analyses, prepared all tables, and contributed, by writing or editing, to all sections of the manuscript.

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