Impact of Post-Intubation Interventions on Mortality in Patients Boarding in the Emergency Department

Abstract

IntroductionEmergency physicians frequently perform endotracheal intubation and mechanical ventilation. The impact of instituting early post-intubation interventions on patients boarding in the emergency department (ED) is not well studied. We sought to determine the impact of post-intubation interventions (arterial blood gas sampling, obtaining a chest x-ray (CXR), gastric decompression, early sedation, appropriate initial tidal volume, and quantitative capnography) on outcomes of mortality, ventilator-associated pneumonia (VAP), ventilator days, and intensive care unit (ICU) length-of-stay (LOS).MethodsThis was an observational, retrospective study of patients intubated in the ED at a large tertiary-care teaching hospital and included patients in the ED for greater than two hours post-intubation. We excluded them if they had incomplete data, were designated “do not resuscitate,” were managed primarily by the trauma team, or had surgery within six hours after intubation.ResultsOf 169 patients meeting criteria, 15 died and 10 developed VAP. The mortality odds ratio (OR) in patients receiving CXR was 0.10 (95% CI 0.01 to 0.98), and 0.11 (95% CI 0.03 to 0.46) in patients receiving early sedation. The mortality OR for patients with 3 or fewer interventions was 4.25 (95% CI 1.15 to 15.75) when compared to patients with 5 or more interventions. There was no significant relationship between VAP rate, ventilator days, or ICU LOS and any of the intervention groups.ConclusionThe performance of a CXR and early sedation as well as performing five or more vs. three or fewer post-intubation interventions in boarding adult ED patients was associated with decreased mortality.

Boarding of critically Ill patients in the emergency department

“…Other common diseases may require critical care in the ED prior to admission, including diabetic ketoacidosis, metabolic derrangements, gastrointestinal hemorrhage, and neurovascular disorders. Unfortunately, the boarding of critically ill patients in the ED is associated with delays in care, which impact broad clinical outcomes in the critically ill 16‐20 …”

“…Several studies defined a time threshold a priori as greater than 2, 4, or 6 hours 16,29‐31 . Two studies assessed boarding based only on the total number of hours an intubated patient spent in the ED 19,32 . The DELAY‐ED study group identified 6 hours in the ED (from time of arrival at triage) as the definition of ED boarding, based primarily on their observations that adverse outcomes among admitted critically ill patients are more common with an ED stay greater than 6 hours 31 .…”

“…Both retrospective and prospective observational studies demonstrate worse outcomes for critically ill patients after ED boarding (Supplemental Table 2, Supplemental Digital Content 1, http://links.lww.com/CCM/F477), including increased duration of mechanical ventilation, longer ICU length of stay, and higher mortality 16,18,19,31,32,38,39 . Increased ED boarding times are associated with worsening organ dysfunction and a four‐fold increase in the probability of poor neurologic recovery in patients presenting with stroke 38 .…”

Prehospital oral chlorhexidine does not reduce the rate of ventilator-associated pneumonia among critically ill trauma patients: A prospective concurrent-control study

“…Chlorhexidine is an antiseptic solution that is applied to the mouth of an intubated patient to decontaminate oral secretions that may colonize the lower airways. No VAP prevention guidelines exist outside the ICU, so strategies to prevent nosocomial infections secondary to traumatic injury are not routinely applied in the prehospital environment or in the ED [19].…”

Emergency Department Blood Gas Utilization and Changes in Ventilator Settings

“…1 While most ventilator changes occur during the first 48 h of ICU admission, 2 a majority of mechanically ventilated patients in the emergency department receive no ventilator changes despite an average emergency department stay of 5-6 h before transfer to the ICU. [3][4][5] A recent study of mechanically ventilated emergency department subjects found an association between an increased number of emergency department interventions after intubation and reduced mortality, 6 demonstrating the need for ongoing monitoring and care of mechanically ventilated emergency department patients. In addition to hemodynamic disturbances, mechanically ventilated emergency department patients are at risk of hypoxemia, hyperoxia, hypercapnia, and acidemia.…”