Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

Out-of-Hospital emergency airway management practices: A nationwide observational study from Aotearoa New Zealand

Background and Objectives

Airway management is crucial for emergency care in critically ill patients outside the hospital setting. An Airway Registry is useful in providing essential information for quality improvement purposes. Therefore, this study aimed to develop an out-of-hospital airway registry and describe airway management practices in Aotearoa New Zealand (AoNZ).

Methods

Data from the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database were used in a retrospective cohort study covering July 2020 to June 2021. All patients receiving airway interventions were included. An airway intervention was defined as one or more of the following: non-drug assisted endotracheal intubation (NDA-ETI), drug-assisted endotracheal intubation (DA-ETI; where a combination of paralytic agent and sedative were used to aid in intubation), laryngeal mask airway (LMA), oropharyngeal airway (OPA), nasopharyngeal airway (NPA), surgical airway (cricothyroidotomy), suction, jaw thrust. Descriptive statistics were analysed using Chi-Square and logistic regression modelling investigated the relationship between advanced airway success and patient characteristics.

Results

The study included 4,529 patients who underwent 7,779 airway interventions. Basic airway interventions were used most frequently: OPA (45.1%), NPA (29.3%), LMA (28.9%), suction (19.9%) and jaw thrust (17.6%). Advanced airway interventions were used less frequently: NDA-ETI (19.8%), DA-ETI (8.7%), and surgical airways (0.2%). The success rate for ETI (including both NDA-ETI and DA-ETI) was 89.4%, with NDA-ETI success at 85.8% and DA-ETI success at 97.7%. ETI first-pass success rates were significantly lower for males (aOR 0.65, 95%CI 0.48-0.87, p < 0.001) and higher for non-cardiac arrest injury patients (aOR 2.94, 95%CI 1.43-6.00, p < 0.001). In this cohort receiving airway interventions the 1-day mortality rate was 41.1%, demonstrating that a high proportion of these patients were severely clinically compromised.

Conclusions

Out-of-hospital airway management practices and success rates in AoNZ are comparable to those elsewhere. This research has determined the variables to be used as the AoNZ Paramedic Airway Registry ongoing and has demonstrated baseline outcomes in airway management for ongoing quality improvement using this registry.

Advanced-level paramedics' support needs for developing and utilising competence

INTRODUCTION

Paramedic competence plays a vital role in emergency medical services (EMS), as the pre-hospital setting demands a wide variety of competencies from paramedics. The aim of the study was to examinethesupportthatadvanced-level paramedics need from their supervisors to develop and utilise their competence.

METHODS

Qualitative essay material was collected from a group of experienced advanced-level paramedics (n = 41). The material was analysed with inductive content analysis.

RESULTS

Twenty-eight sub-categories emerged, forming 6 categories further leading to the grouping of two main categories: 1) the enablement of human resource (HR) management and leadership; and 2) guidelines on how to operate EMS adequately.

CONCLUSIONS

Supervisors can and should support advanced-level paramedics in their competence utilisation and development. This can be achieved by enabling professional growth by recognising competencies and generating supportive leadership in EMS. Paramedics would also benefit from clear operative guidelines. Overall, supporting paramedics' competence utilisation and development is strongly connected with leadership standards in daily practices.

Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts

BACKGROUND

Lower intubation first-pass success (FPS) rate is associated with physiological deterioration, and FPS is widely used as a quality indicator of the airway management of a critically ill patient. However, data on FPS's association with survival is limited. We aimed to investigate if the FPS rate is associated with 30-day mortality or physiological complications in a pre-hospital setting. Furthermore, we wanted to describe the FPS rate in Finnish helicopter emergency medical services.

METHODS

This was a retrospective observational study. Data on drug-facilitated intubation attempts by helicopter emergency medical services were gathered from a national database and analysed. Multivariate logistic regression, including known prognostic factors, was performed to assess the association between FPS and 30-day mortality, collected from population registry data.

RESULTS

Of 4496 intubation attempts, 4082 (91%) succeeded on the first attempt. The mortality rates in FPS and non-FPS patients were 34% and 38% (P = 0.21), respectively. The adjusted odds ratio of FPS for 30-day mortality was 0.88 (95% CI 0.66-1.16). Hypoxia after intubation and at the time of handover was more frequent in the non-FPS group (12% vs. 5%, P < 0.001, and 5% vs. 3%, P = 0.01, respectively), but no significant differences were observed regarding other complications.

CONCLUSION

FPS is not associated with 30-day mortality in pre-hospital critical care delivered by advanced providers. It should therefore be seen more as a process quality indicator instead of a risk factor of poor outcome, at least considering the current limitations of the parameter.