Assessing Advanced Airway Management Performance in a National Cohort of Emergency Medical Services Agencies.

STUDY OBJECTIVE: Although often the focus of quality improvement efforts, emergency medical services (EMS) advanced airway management performance has few national comparisons, nor are there many assessments with benchmarks accounting for differences in agency volume or patient mix. We seek to assess variations in advanced airway management and conventional intubation performance in a national cohort of EMS agencies. METHODS: We used EMS data from ESO Solutions, a national EMS electronic health record system. We identified EMS emergency responses with attempted advanced airway management (conventional intubation, rapid sequence intubation, sedation-assisted intubation, supraglottic airway insertion, and cricothyroidotomy). We also separately examined cases with initial conventional intubation. We determined EMS agency risk-standardized advanced airway management and initial conventional intubation success rates by using mixed-effects regression models, fitting agency as a random intercept, adjusting for patient age, sex, race, cardiac arrest, or trauma status, and use of rapid sequence or sedation-assisted intubation, and accounting for reliability variations from EMS agency airway volume. We assessed changes in agency advanced airway management and initial conventional intubation performance rank after risk and reliability adjustment. We also identified high and low performers (reliability-adjusted and risk-standardized success confidence intervals falling outside the mean). RESULTS: During 2011 to 2015, 550 EMS agencies performed 57,209 advanced airway management procedures. Among 401 EMS agencies with greater than or equal to 10 advanced airway management procedures, there were a total of 56,636 procedures. Median reliability-adjusted and risk-standardized EMS agency advanced airway management success was 92.9% (interquartile range 90.1% to 94.8%; minimum 58.2%; maximum 99.0%). There were 56 advanced airway management low-performing and 38 high-performing EMS agencies. Among 342 agencies with greater than or equal to 10 initial conventional intubations, there were a total of 37,360 initial conventional intubations. Median reliability-adjusted and risk-standardized EMS agency initial conventional intubation success was 77.3% (interquartile range 70.9% to 83.6%; minimum 47.1%; maximum 95.8%). There were 64 initial conventional intubation low-performing and 45 high-performing EMS agencies. CONCLUSION: In this national series, EMS advanced airway management and initial conventional intubation performance varied widely. Reliability adjustment and risk standardization may influence EMS airway management performance assessments.

Advanced airway management success rates in a national cohort of emergency medical services agencies.

OBJECTIVE: Despite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies. METHODS: We used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011-2015 with attempted AAM. We categorized AAM techniques as conventional endotracheal intubation (cETI), neuromuscular blockade assisted intubation (NMBA-ETI), supraglottic airway (SGA), and cricothyroidotomy (needle and open). Determination of successful AAM was based on EMS provider report. We analyzed the data using descriptive statistics, determining the incidence and clinical characteristics of AAM cases. We determined success rates for each AAM technique, stratifying by the subsets cardiac arrest, medical non-arrest, trauma, and pediatrics (age ≤12 years). RESULTS: AAM occurred in 57,209 patients. Overall AAM success was 89.1% (95% CI: 88.8-89.3%) across all patients and techniques. Intubation success rates varied by technique; cETI (n = 38,004; 76.9%, 95% CI: 76.5-77.3%), NMBA-ETI (n = 6768; 89.7%, 88.9-90.4%). SGAs were used both for initial (n = 9461, 90.1% success, 95% CI: 89.5-90.7%) and rescue (n = 5994, 87.3% success, 95% CI: 86.4-88.1%) AAM. Cricothyroidotomy success rates were low: initial cricothyroidotomy (n = 202, 17.3% success, 95% CI: 12.4-23.3%), rescue cricothyroidotomy (n = 85, 52.9% success, 95% CI: 41.8-88%). AAM success rates varied by patient subset: cardiac arrest (n = 35,782; 91.7%, 95% CI: 91.4-92.0), medical non-arrest (n = 17,086; 84.7%, 84.2-85.2%); trauma (n = 4341; 84.3%, 83.1-85.3%); pediatric (n = 1223; 73.7%, 71.2-76.2%). CONCLUSION: AAM success rates varied by airway technique and patient subset. In this national cohort, these results offer perspectives of EMS AAM practices.

Defining the plateau point: When are further attempts futile in out-of-hospital advanced airway management?

BACKGROUND: We sought to characterize the number of attempts required to achieve advanced airway management (AAM) success. METHODS: Using 4 years of data from a national EMS electronic health record system, we examined the following subsets of attempted AAM: 1) cardiac arrest intubation (CA-ETI), 2) non-arrest medical intubation (MED-ETI), 3) non-arrest trauma intubation (TRA-ETI), 4) rapid-sequence intubation (RSI), 5) sedation-assisted ETI (SAI), and 6) supraglottic airway (SGA). We determined the first pass and overall success rates, as well as the point of additional attempt futility ("plateau point"). RESULTS: Among 57,209 patients there were 64,291 AAM. CA-ETI performance was: first-pass success (FPS) 71.4% (95% CI: 70.9-71.9%), 4 attempts to reach 91.5% (91.2-91.9%) success plateau. MED-ETI performance was: FPS 66.0% (95% CI: 65.1-67.0%), 3 attempts to reach 79.2% (78.4-80.0%) success plateau. TRA-ETI performance was: FPS 61.6% (95% CI: 59.3-63.9%), 3 attempts to reach 75.8% (73.7-77.8%) success plateau. RSI performance was: FPS 76.1% (95% CI: 75.1-77.1%), 5 attempts to reach 95.8% (95.3-96.2%) success plateau. SAI performance was: FPS 66.9% (95% CI: 65.1-68.6%), 3 attempts to 85.3% (83.9-86.6%) success plateau. SGA performance was: FPS 88.7% (95% CI: 88.0-89.3%), 5 attempts to reach 92.8% (92.3-93.4%) success plateau. CONCLUSION: Multiple attempts are often needed to accomplish successful AAM. The number of attempts needed to accomplish AAM varies with AAM technique. These results may guide AAM practices.