Student paramedic rapid sequence intubation in Johannesburg, South Africa: A case series

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa

Introduction

Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success.

Methods

This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS.

Results

A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20–0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36–0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25–0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985–0.997, p < 0.01) was inversely associated FPS.

Conclusion

This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00688-4.

Prehospital Airway Management for Trauma Patients by First Responders in Six Sub-Saharan African Countries and Five Other Low- and Middle-Income Countries: A Scoping Review

The global injury burden disproportionately affecting low- and middle-income countries (LMICs) is exacerbated by a lack of robust emergency medical services. Though airway management (AM) is an essential component of prehospital emergency care, the current standard of prehospital AM training and resources for first responders in LMICs is unknown. This scoping review includes articles published between January 2000 and June 2021, identified using PMC, MEDLINE, and SCOPUS databases, following PRISMA-ScR guidelines. Inclusion criteria spanned programs training formal or informal prehospital first responders. Included articles were assessed for quality using the Newcastle-Ottawa scale. Relevant characteristics were extracted by multiple authors to assess prehospital AM training. Of the initial 713 articles, 17 met inclusion criteria, representing 11 countries. Basic AM curricula were found in 11 studies and advanced AM curricula were found in nine studies. 35.3% (n = 6) of first responder programs provided no equipment to basic life support (BLS) AM training participants, reporting a median cost of $7.00USD per responder trained. Median frequency of prehospital AM intervention was reported in 31.0% (IQR: 6.0, 50.0) of patient encounters (advanced life support trainees: 12.1%, BLS trainees: 32.0%). In three studies, adverse event frequencies during intubation occurred with a median frequency of 22.0% (IQR: 21.0, 22.0). The training deficit in advanced AM interventions in LMICs suggests BLS AM courses should be prioritized, especially in sub-Saharan Africa. Prehospital AM resources are sparse and should be a priority for future development.

Rapid Intubation Sequence: 4-Year Experience in an Emergency Department

Background

The rapid intubation sequence is advanced airway management that effectively ensures an adequate supply of oxygen in critically ill patients. The medical personnel in the emergency department performed this procedure.

Objective

To describe the main characteristics of the rapid intubation sequence in an emergency department of a high complexity hospital.

Methods

This is a descriptive, cross-sectional, retrospective study. We included all older patients with a rapid intubation sequence requirement in the emergency department from 2014 to 2017. We used central tendency measures for numerical variables and proportions for categorical variables.

Results

A total of 401 patients were eligible for this analysis. The main indication for intubation was the Glasgow Coma Scale = <8 in 170 patients (42.4%), followed by hypoxemia in 142 patients (35.4%). In 36 patients, at least one complication occurred. RSI was performed in 54.4% by emergency physician. RSI was successful on the first attempt in 90.5%. Only 36 patients (9%) presented complications.

Conclusion

In this study, we found that the rapid intubation sequence was not related to a high proportion of complications. Perhaps, this is attributed to the degree of medical training and the use of emergency department protocols in our hospital.

Rapid sequence intubation: a survey of current practice in the South African pre-hospital setting

Background

Rapid sequence intubation (RSI) is an advanced airway skill commonly performed in the pre-hospital setting globally. In South Africa, pre-hospital RSI was first approved for non-physician providers by the Health Professions Council of South Africa in 2009 and introduced as part of the scope of practice of degree qualified Emergency Care Practitioners (ECPs) only. The research study aimed to investigate and describe, based on the components of the minimum standards of pre-hospital RSI in South Africa, specific areas of interest related to current pre-hospital RSI practice.

Methods

An online descriptive cross-sectional survey was conducted amongst operational ECPs in the pre-hospital setting of South Africa, using convenience and snowball sampling strategies.

Results

A total of 87 participants agreed to partake. Eleven (12.6%) incomplete survey responses were excluded while 76 (87.4%) were included in the data analysis. The survey response rate could not be calculated. Most participants were operational in Gauteng (n = 27, 35.5%) and the Western Cape (n = 25, 32.9%). Overall participants reported that their education and training were perceived as being of good quality. The majority of participants (n = 69, 90.8%) did not participate in an internship programme before commencing duties as an independent practitioner. Most RSI and post-intubation equipment were reported to be available; however, our results found that introducer stylets and/or bougies and end-tidal carbon dioxide devices are not available to some participants. Only 50 (65.8%) participants reported the existence of a clinical governance system within their organisation. Furthermore, our results indicate a lack of clinical feedback, deficiency of an RSI database, infrequent clinical review meetings and a shortage of formal consultation frameworks.

Conclusion

The practice of safe and effective pre-hospital RSI, performed by non-physician providers or ECPs, relies on comprehensive implementation and adherence to all the components of the minimum standards. Although there is largely an apparent alignment with the minimum standards, recurrent revision of practice needs to occur to ensure alignment with recommendations. Additionally, some areas may benefit from further research to improve current practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-021-00368-3.