Comparison of different intubation techniques performed inside a moving ambulance: a manikin study.

OBJECTIVE. Airway management and endotracheal intubation may be required urgently when a patient deteriorates in an ambulance or aircraft during interhospital transfer or in a prehospital setting. The objectives of this study were: (1) to compare the effectiveness of conventional intubation by Macintosh laryngoscope in a moving ambulance versus that in a static ambulance; and (2) to compare the effectiveness of inverse intubation and GlideScope laryngoscopy with conventional intubation inside a moving ambulance. DESIGN. Comparative experimental study. SETTING. The experiment was conducted in an ambulance provided by the Auxiliary Medical Service in Hong Kong. PARTICIPANTS. A group of 22 doctors performed endotracheal intubation on manikins with Macintosh laryngoscope in a static and moving ambulance. In addition, they performed conventional Macintosh intubation, inverse intubation with Macintosh laryngoscope, and GlideScope intubation in a moving ambulance in both normal and simulated difficult airways. MAIN OUTCOME MEASURES. The primary outcome was the rate of successful intubation. The secondary outcomes were time taken for intubation, subjective glottis visualisation grading, and eventful intubation (oesophageal intubation, intubation time >60 seconds, and incisor breakage) with different techniques or devices. RESULTS. In normal airways, conventional Macintosh intubation in a static ambulance (95.5%), conventional intubation in a moving ambulance (95.5%), as well as GlideScope intubation in a moving ambulance (95.5%) were associated with high success rates; the success rate of inverse intubation was comparatively low (54.5%; P=0.004). In difficult airways, conventional Macintosh intubation in a static ambulance (86.4%), conventional intubation in a moving ambulance (90.9%), and GlideScope intubation in a moving ambulance (100%) were associated with high success rates; the success rate of inverse intubation was comparatively lower (40.9%; P=0.034). CONCLUSIONS. En-route intubation in an ambulance by conventional Macintosh laryngoscopy is superior to inverse intubation unless the cephalad access is impossible. GlideScope laryngoscopy appears to be associated with lower rates of eventful intubation in difficult airways and has better laryngoscopic view versus inverse intubation.

Evaluation of a simplified therapeutic intervention scoring system (TISS-28) and the modified early warning score (MEWS) in predicting physiological deterioration during inter-facility transport.

INTRODUCTION: There is an emerging demand for inter-facility transport (IFT) of patients in recent years following changes in the healthcare framework in Hong Kong but this carries certain risks. Anticipation of possible deterioration of patients is important for patient safety and therefore risk stratification of patients before transport is important. OBJECTIVE: This study evaluated the simplified therapeutic intervention scoring system (TISS-28) and modified early warning score (MEWS) in predicting physiological deterioration en route. METHODS: This is a prospective single centre study of all emergency IFT for adult patients, excluding patients with obstetric conditions, occurring between 1 January 2005 and 30 June 2006. The severity of illness was quantified in terms of TISS-28 and MEWS. Mann-Whitney test and receiver operator characteristic (ROC) curves were used to illustrate and compare their performance. RESULTS: Among 102 patients requiring IFT, 28 had physiological deterioration en route (27%). The TISS-28 scores upon dispatch ranged from 5 to 34 with a mean of 16.5+/-5.71 whereas MEWS ranged from 0 to 11 with a mean of 2.82+/-2.01. The incidence of physiological deterioration en route was significantly greater with a higher MEWS score (P=0.001) but this was not seen with the TISS-28 score. The area under the ROC curve for the predictive value of MEWS was 0.71 which performed better than TISS-28 (area under the curve=0.53). CONCLUSION: IFT represents a group of patients with vast heterogeneity. TISS-28 is not a useful tool for risk stratification prior to transport. MEWS was able to identify patients at risk but was not ideal.

Knowledge of inter-facility transport among emergency nurses in Hong Kong: a questionnaire survey.

INTRODUCTION: Inter-facility transport (IFT) is a dynamic process and its quality largely depends on pre-transport preparation, emergency equipment support and recognition of possible en route adverse events. This study aims to evaluate knowledge of IFT among emergency nurses of three Accident and Emergency Departments in Hong Kong. METHODS: Questionnaires were distributed to registered nurses of the three departments. Data was sought on participants' characteristics, knowledge on equipment preparation and management of en route adverse events. Four clinical IFT scenarios were set for participants and answers were scored. Measured outcomes were defined as (1) relationships between clinical experience and relevant training in IFT with questionnaire results, (2) staff knowledge of the equipment carried routinely in ambulances and (3) the en route adverse events encountered according to the participants' past experience. RESULTS: Participants' test scores ranged from 24 to 37 (out of 40) with a mean of 30.6 (95% confidence interval 29.7-31.5). Participants with more clinical experience demonstrated significantly better test scores (p<0.05). Most participants were familiar with the monitoring devices carried in ambulances but were less familiar with the pharmacologic agents and airway devices available routinely in Hong Kong ambulances. Thirty participants (59%) had encountered en route adverse events in the past. CONCLUSION: Nurses in emergency departments in Hong Kong have good knowledge of IFT. Extensive clinical experience is related to better IFT knowledge. IFT training for nurses should emphasize available ambulance service resources and capabilities.