Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan

Abstract

BackgroundA reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway.MethodsThis historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation.ResultsOf the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1–5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1–8.4; p = 0.034).ConclusionsIn this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway. These data imply the need for more attentive hospital care during nights and weekends.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0296-2) contains supplementary material, which is available to authorized users.

Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department

“…In our ED, a chest X-ray or computed tomography scan is routinely performed after tube placement to detect mainstem bronchus intubation. For consistency with our own studies and those of other researchers [ 20 , 21 ], off hours were defined as the period from 6:01 PM to 8:00 AM on weekdays plus the entire weekend.…”

“…ETI-associated complications were defined as hypoxemia, esophageal intubation with delayed recognition, cardiac arrest immediately after ETI attempt, recorded regurgitation, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak requiring intubation, or mainstem bronchus intubation. Hypoxemia was defined as a decline in pulse oximetry saturation > 10% from baseline during ETI attempts, not resulting from esophageal intubation [ 21 – 24 ]. Esophageal intubation with delayed recognition was defined as misplacement of the endotracheal tube in the upper esophagus or hypopharynx, with time elapsed and desaturation (> 10% decline in pulse oximetry saturation) also recorded [ 21 – 24 ].…”

“…Hypoxemia was defined as a decline in pulse oximetry saturation > 10% from baseline during ETI attempts, not resulting from esophageal intubation [ 21 – 24 ]. Esophageal intubation with delayed recognition was defined as misplacement of the endotracheal tube in the upper esophagus or hypopharynx, with time elapsed and desaturation (> 10% decline in pulse oximetry saturation) also recorded [ 21 – 24 ]. Recorded regurgitation was defined as the immediate peri-induction regurgitation of gastric contents at the glottis opening or in the endotracheal tube, clearly documented in the ED or nursing records [ 21 – 24 ].…”

“…Esophageal intubation with delayed recognition was defined as misplacement of the endotracheal tube in the upper esophagus or hypopharynx, with time elapsed and desaturation (> 10% decline in pulse oximetry saturation) also recorded [ 21 – 24 ]. Recorded regurgitation was defined as the immediate peri-induction regurgitation of gastric contents at the glottis opening or in the endotracheal tube, clearly documented in the ED or nursing records [ 21 – 24 ]. Cardiac arrest immediately after an ETI attempt included asystole, bradycardia, or dysrhythmia in a patient without a measurable blood pressure and requiring cardiopulmonary resuscitation during or immediately after the ETI attempt [ 21 – 24 ].…”

Advancing emergency airway management practice and research

“…We believe that, in collaborative efforts between research teams that are adept at generating high‐quality science, such investigations will provide emergency physicians with important opportunities for improving the quality and safety of airway management practice. For researchers and professional organizations, the gained knowledge will not only advance research into the determination of optimal airway management strategies but also facilitate the development of high‐quality clinical guidelines as well as their dissemination to the EDs nationally, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.…”