Patient status and time to intubation in the assessment of prehospital intubation performance

Tick-tock: Prehospital intubation is associated with longer field time without any survival benefit

BACKGROUND

Prehospital endotracheal intubation is a debated topic, and few studies have found it beneficial after trauma. A growing body of evidence suggests that prehospital endotracheal intubation is associated with increased morbidity and mortality. Our study was designed to compare patients with attempted prehospital endotracheal intubation to those intubated promptly upon emergency department arrival.

METHODS

A retrospective review of a single-center trauma research data repository was utilized. Inclusion criteria included age ≥15 years, transport from the scene by ground ambulance, and undergoing prehospital endotracheal intubation attempts or intubation within 10 minutes of emergency department arrival without prior prehospital endotracheal intubation attempt. Propensity score matching was used to minimize differences in baseline characteristics between groups. Standard mean differences are also presented for pre- and post-matching datasets to evaluate for covariate balance.

RESULTS

In total, 208 patients met the inclusion criteria. Of these, 95 patients (46%) underwent prehospital endotracheal intubation, which was successful in 47% of cases. A control group of 113 patients (54%) were intubated within 10 minutes of emergency department arrival. We performed propensity score matching between cohorts based on observed differences after univariate analysis and used standard mean differences to estimate covariate balance. After propensity score matching, patients who underwent prehospital endotracheal intubation experienced a longer time on scene as compared with those intubated in the emergency department (9 minutes [interquartile range 6-12] vs 6 minutes [interquartile range 5-9], P < .01) without difference in overall mortality (67% vs 65%, P = 1.00). Rapid sequence intubation was not used in the field; however, it was used for 58% of patients intubated within 10 minutes of emergency department arrival. After matched analysis, patients with a failed prehospital intubation attempt were equally likely to receive rapid sequence intubation during re-intubation in the emergency department as compared with those undergoing a first attempt (n = 13/28, 46% vs n = 28/63, 44%, P = 1.00, standard mean differences 0.04). Among patients with prehospital arrest (n = 98), prehospital endotracheal intubation was associated with shorter time to death (8 minutes [interquartile range 3-17] vs 14 minutes [interquartile range 8-45], P = .008) and longer total transport time (23 minutes [interquartile range 19-31] vs 19 minutes [interquartile range 16-24], P = .006), but there was no difference in observed mortality (n = 29/31, 94% vs n = 30/31, 97%, P = 1.00, standard mean differences = 0.15) after propensity score matching.

CONCLUSION

Prehospital providers should prioritize expeditious transport over attempting prehospital endotracheal intubation, as prehospital endotracheal intubation is inconsistently successful, may delay definitive care, and appears to have no survival benefit.

Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting

OBJECTIVE

This study attempts to determine if newer indirect laryngoscopes or intubating devices are superior to a standard laryngoscope for intubation success among helicopter emergency medical service (HEMS) personnel.

METHODS

Flight nurses and paramedics intubated standardized mannequins with a normal airway, a trauma airway, and a difficult airway using a standard laryngoscope, a gum elastic bougie, the Airtraq laryngoscope (King System Corp, Noblesville, IN), the Glidescope Ranger laryngoscope (Verathon Inc, Bothell, WA), and the S.A.L.T. device (Microtek Medical, Inc, Lehmberg, IN) in grounded helicopters wearing helmets and flight gear. Participant demographics, time to glottic view, the modified Cormack-Lehane score, total intubation time, number of attempts, and overall successful intubation were recorded for each type of airway.

RESULTS

Two-hundred thirty-six subjects were initially enrolled across 107 bases in 15 states, and 177 completed the study. First-attempt success rates did not vary by device for the normal airway (P = .203), but the Airtraq laryngoscope and the S.A.L.T. device were highest in the difficult airway (82.0% and 85.0%, respectively; P < .0001). The time to first-attempt success in the difficult airway was lowest for the S.A.L.T. device and the Airtraq laryngoscope (mean = 9.72 seconds and 19.70 seconds, respectively; P < .0001).

CONCLUSION

Using HEMS providers, the Airtraq laryngoscope and the S.A.L.T. device showed the fastest and highest intubation success on the first attempt in difficult simulated HEMS airway scenarios.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Tracheal intubation related complications in the prehospital setting

BACKGROUND

Prehospital tracheal intubation (TI) is associated with morbidity and mortality, particularly in cases of difficult intubation. The goal of the present study was to describe factors associated with TI related complications in the prehospital setting.

METHODS

This was a prospective cohort study including all patients intubated on scene in a prehospital emergency medical service over a 4 year period. TI related complications included oxygen desaturation, aspiration, vomiting, bronchospasm and/or laryngospasm, and mechanical complications (mainstem intubation, oesophageal intubation and airway lesion- that is, dental or laryngeal trauma caused by the laryngoscope). Difficult intubation was defined as >2 failed laryngoscopic attempts, or the need for any alternative TI method. A multivariate logistic regression was used to identify the risk factors for TI related complications.

RESULTS

1251 patients were included; 208 complications occurred in 165 patients (13.1%). Among the 208 complications, the most frequent were oesophageal intubation (n=69, 29.7%), desaturation (n=58, 25.0%) and mainstem intubation (n=37, 15.9%). In multivariate analysis, difficult intubation (OR=6.13, 3.93 to 9.54), Cormack and Lehane grades 3 and 4 (OR=2.23, 1.26 to 3.96 for Cormack and Lehane grade 3 and OR=2.61, 1.28 to 5.33 for Cormack and Lehane grade 4 compared with Cormack and Lehane grade 1) and a body mass index >30 kg/m(2) (OR=2.22, 1.38 to 3.56) were significantly associated with TI related complications.

CONCLUSIONS

Despite specific guidelines, TI related complications are more frequent in the prehospital setting when intubation is deemed difficult, the Cormack and Lehane grade is greater than grade 1 and the patient is overweight. In such situations, particular attention is needed to avoid complications.

The Airtraq Optical Laryngoscope in helicopter emergency medical services: a pilot trial

OBJECTIVE

To determine the degree of success helicopter emergency medical services personnel have in placing an endotracheal tube using a relatively new device for endotracheal intubation (ETI) known as the Airtraq (AT) Optical Laryngoscope (King Systems Corp, Noblesville, IN), and to determine the frequency with which flight crews had to resort to other means for advanced airway management.

METHODS

This prospective, observational pilot trial evaluated the critical care flight team's ability to perform ETI using the AT as a first-line device in the prehospital setting. Flight crews were instructed to use the AT for any patient needing ETI. Teams completed a 30-minute training session followed by mannequin practice. They documented situations and outcomes: reason for ETI, success in placing the AT, reason for unsuccessful placement, end-tidal carbon dioxide concentration in expired air (ETCO2), and where patients were when they underwent intubation (field, ambulance, aircraft, hospital). Data were abstracted and analyzed using JMP software version 7.0 (SAS Institute, Inc, Cary, NC).

RESULTS

Fifty cases involving use of the AT were analyzed. Median patient age was 51.5 years (range, 15-90; interquartile range, 36-64.5). Most patients were male (n = 37 [74%]). The primary reasons for intubation were unresponsiveness and altered loss of consciousness (n = 23 [46%]), respiratory distress or apnea (n = 8 [16%]), cardiac arrest (n = 10 [20%]), and combative behavior (n = 7 [14%]). AT was successful (n = 31[62%]) in 1 to 2 attempts. The primary reason for AT failure was blood or vomit in the airway (n = 8 [42.1%]); 48.1% (n = 25) of patients required a different management mode.

CONCLUSIONS

HEMS crews had difficulty placing successful ET tubes with this device after minimal education with a single regular-sized device. Difficulty was pronounced when blood or vomit was present and obstructing the optical view. Further study is needed to evaluate the implementation time, training time required, and possible design advantages of the AT compared with those of traditional emergent airway management techniques.

Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

Introduction

Pre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.

Methods

We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.

Results

From 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).

Conclusions

This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.

Medication dosing errors in pediatric patients treated by emergency medical services

BACKGROUND

Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by emergency medical services (EMS) paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients.

OBJECTIVE

To characterize medication dosing errors in children treated by EMS.

METHODS

We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight-appropriate dose, as determined by the patient's reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and naloxone.

RESULTS

There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% ± 428%. The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine underdoses was 35.5% ± 27.4%.

CONCLUSIONS

Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing errors.

Medical conditions associated with out-of-hospital endotracheal intubation

BACKGROUND

While prior studies describe the clinical presentation of patients requiring paramedic out-of-hospital endotracheal intubation (ETI), limited data characterize the underlying medical conditions or comorbidities.

OBJECTIVE

To characterize the medical conditions and comorbidities of patients receiving successful paramedic out-of-hospital ETI.

METHODS

We used Pennsylvania statewide emergency medical services (EMS) clinical data, including all successful ETIs performed during 2003-2005. Using multiple imputation triple-match algorithms, we probabilistically linked EMS ETI to statewide death and hospital admission data. Each hospitalization record contained one primary and up to eight secondary diagnoses, classified according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We determined the proportion of patients in each major ICD-9-CM diagnostic group and subgroup. We calculated the Charlson Comorbidity Index score for each patient. Using binomial proportions with confidence intervals (CIs), we analyzed the data and combined imputed results using Rubin's method.

RESULTS

Across the imputed sets, we linked 25,733 (77.7% linkage) successful ETIs to death or hospital records; 56.3% patients died before and 43.7% survived to hospital admission. Of the 14,478 patients who died before hospital admission, most (92.7%; 95% CI: 92.5-93.3%) had presented to EMS in cardiac arrest. Of the 11,255 hospitalized patents, the leading primary diagnoses were circulatory diseases (32.0%; 95% CI: 30.2-33.7%), respiratory diseases (22.8%; 95% CI: 21.9-23.7%), and injury or poisoning (25.2%; 95% CI: 22.7-27.8%). Prominent primary diagnosis subgroups included asphyxia and respiratory failure (15.2%), traumatic brain injury and skull fractures (11.3%), acute myocardial infarction and ischemic heart disease (10.9%), poisonings and drug and alcohol disorders (6.7%), dysrhythmias (6.7%), hemorrhagic and nonhemorrhagic stroke (5.9%), acute heart failure and cardiomyopathies (5.6%), pneumonia and aspiration (4.9%), and sepsis, septicemia, and septic shock (3.2%). Most of the admitted ETI patients had a secondary circulatory (70.8%), respiratory (61.4%), or endocrine, nutritional, or metabolic (51.4%) secondary diagnosis. The mean Charlson Index score was 1.6 (95% CI: 1.5-1.7).

CONCLUSIONS

The majority of successful paramedic ETIs occur on patients with cardiac arrest and circulatory and respiratory conditions. Injuries, poisonings, and other conditions compromise smaller but important portions of the paramedic ETI pool. Patients undergoing ETI have multiple comorbidities. These findings may guide the systemic planning of paramedic airway management care and education.

The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale Scores of 8 or less

BACKGROUND

Airway management remains a fundamental component of optimal care of the severely injured patient, with endotracheal intubation representing the definitive strategy for airway control. However, multiple studies document an association between out-of-hospital intubation and increased mortality for severe traumatic brain injury.

OBJECTIVES

To explore the relationship between out-of-hospital intubation attempts and outcome among trauma patients with Glasgow Coma Scale (GCS) scores ≤ 8 across sites participating in the Resuscitation Outcomes Consortium (ROC).

METHODS

The ROC Epistry-Trauma, an epidemiologic database of prehospital encounters with critically injured trauma victims, was used to identify emergency medical services (EMS)-treated patients with GCS scores ≤ 8. Multiple logistic regression was used to explore the association between intubation attempts and vital status at discharge, adjusting for the following covariates: age, gender, GCS score, hypotension, mechanism of injury, and ROC site. Sites were then stratified by frequency of intubation attempts and chi-square test for trend was used to associate the frequency of intubation attempts with outcome.

RESULTS

A total of 1,555 patients were included in this analysis; intubation was attempted in 758 of these. Patients in whom intubation was attempted had higher mortality (adjusted odds ratio [OR] 2.91, 95% confidence interval [CI] 2.13-3.98, p < 0.01). However, sites with higher rates of attempted intubation had lower mortality across all trauma victims with GCS scores ≤ 8 (OR 1.40, 95% CI 1.15-1.72, p < 0.01).

CONCLUSIONS

Patients in whom intubation is attempted have higher adjusted mortality. However, sites with a higher rate of attempted intubation have lower adjusted mortality across the entire cohort of trauma patients with GCS scores ≤ 8. Coma Scale score.

Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables

Introduction

Although tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures, providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables and 12 fixed-system variables) found in current scientific publications on pre-hospital TI.

Methods

We performed an all time systematic search according to the PRISMA guidelines of Medline and EMBASE to identify original research pertaining to pre-hospital TI in adult patients.

Results

From 1,076 identified records, 73 original papers were selected. Information was extracted according to an Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR 8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most frequently reported variables were "patient category" and "service mission type", reported in 86% and 71% of the studies, respectively. Among the least-reported variables were "co-morbidity" and "type of available ventilator", both reported in 2% and 1% of the studies, respectively.

Conclusions

Core data required for proper interpretation of results were frequently not recorded and reported in studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design must be improved to substantiate future evidence based clinical practice.

The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients

OBJECTIVES

The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA.

METHODS

This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts.

RESULTS

There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt.

CONCLUSIONS

Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations.

Out-of-hospital endotracheal intubation experience and patient outcomes

STUDY OBJECTIVE

Previous studies suggest improved patient outcomes for providers who perform high volumes of complex medical procedures. Out-of-hospital tracheal intubation is a difficult procedure. We seek to determine the association between rescuer procedural experience and patient survival after out-of-hospital tracheal intubation.

METHODS

We analyzed probabilistically linked Pennsylvania statewide emergency medicine services, hospital discharge, and death data of patients receiving out-of-hospital tracheal intubation. We defined tracheal intubation experience as cumulative tracheal intubation during 2000 to 2005; low=1 to 10 tracheal intubations, medium=11 to 25 tracheal intubations, high=26 to 50 tracheal intubations, and very high=greater than 50 tracheal intubations. We identified survival on hospital discharge of patients intubated during 2003 to 2005. Using generalized estimating equations, we evaluated the association between patient survival and out-of-hospital rescuer cumulative tracheal intubation experience, adjusted for clinical covariates.

RESULTS

During 2003 to 2005, 4,846 rescuers performed tracheal intubation. These individuals performed tracheal intubation on 33,117 patients during 2003 to 2005 and 62,586 patients during 2000 to 2005. Among 21,753 cardiac arrests, adjusted odds of survival was higher for patients intubated by rescuers with very high tracheal intubation experience; adjusted odds ratio (OR) versus low tracheal intubation experience: very high 1.48 (95% confidence interval [CI] 1.15 to 1.89), high 1.13 (95% CI 0.98 to 1.31), and medium 1.02 (95% CI 0.91 to 1.15). Among 8,162 medical nonarrests, adjusted odds of survival were higher for patients intubated by rescuers with high and very high tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.55 (95% CI 1.08 to 2.22), high 1.29 (95% CI 1.04 to 1.59), and medium 1.16 (95% CI 0.97 to 1.38). Among 3,202 trauma nonarrests, survival was not associated with rescuer tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.84 (95% CI 0.89 to 3.81), high 1.25 (95% CI 0.85 to 1.85), and medium 0.92 (95% CI 0.67 to 1.26).

CONCLUSION

Rescuer procedural experience is associated with improved patient survival after out-of-hospital tracheal intubation of cardiac arrest and medical nonarrest patients. Rescuer procedural experience is not associated with patient survival after out-of-hospital tracheal intubation of trauma nonarrest patients.

Performance of Resuscitation Skills by Paramedic Personnel in Chemical Protective Suits

OBJECTIVES

Determine whether wearing a chemical protective suit increases time to successful completion of four resuscitation skills.

METHODS

This prospective experimental study examined the ability of civilian paramedic personnel to complete four resuscitative skills (electrical defibrillation, administration of epinephrine subcutaneously, intravenous cannulation, and tracheal intubation) carried out using standard methods on mannequins under two test conditions (wearing the protective suit and not wearing the suit). Primary outcome was time to successful completion of each skill.

RESULTS

Sixteen paramedics were enrolled and completed each skill under two test conditions. Paramedics took longer to complete administration of epinephrine (87 vs. 60 seconds; p < 0.01) and intravenous cannulation (220 vs. 158 seconds; p < 0.01) tasks when wearing a protective suit. Wearing the suit did not impair electrical defibrillation (57 vs. 46 seconds) or tracheal intubation (79 vs 69 seconds).

CONCLUSIONS

Chemical protective suit use increased time to successful completion of resuscitation skills where fine motor skills are required, namely administration of epinephrine subcutaneously and intravenous cannulation, but did not increase time to successful completion of resuscitation skills requiring gross motor skills, namely electrical defibrillation and tracheal intubation.

An Algorithmic Approach to Prehospital Airway Management

Airway management, including endotracheal intubation, is considered one of the most important aspects of prehospital medical care. This concept paper proposes a systematic algorithm for performing prehospital airway management. The algorithm may be valuable as a tool for ensuring patient safety and reducing errors as well as for training rescuers in airway management.

Drug-Assisted Effects on Protective Airway Reflexes During Out-of-Hospital Endotracheal Intubation (Preliminary Report)

OBJECTIVE

Out-of-hospital rescuers often use drug-assisted intubation (DAI) to facilitate endotracheal intubation (ETI) of nonarrest patients. However, the relationship between the ablation of individual protective airway reflexes and resulting DAI success has not been defined. We sought to describe the relationship between the depression or ablation of protective airway reflexes and DAI success.

METHODS

We analyzed data from a prospective multicenter trial. Rescuers from 42 emergency medical services systems reported clinical ETI data using standardized reporting forms. We analyzed the subset receiving sedative and/or neuromuscular blocking agents to facilitate ETI. We defined successful ETI as intratracheal placement of the endotracheal tube on the last ETI attempt. Rescuers reported the presence and ablation of six protective airway reflexes, including the presence of a gag, trismus, inadequate relaxation, combativeness, laryngospasm, and seizure/myoclonus. We examined the relationship between protective reflex ablation and DAI success.

RESULTS

Of 1,953 ETIs, 208 (10.7%) used DAI (128 sedation only, 80 neuromuscular blocking agents/rapid sequence intubation). Successful DAI was associated with ablation of gag reflex (odds ratio [OR], 12.7; 95% confidence interval [CI] 3.7 to 46.2), clenched jaw/trismus (OR, 54.4; 95% CI, 11.1 to 292.4), inadequate relaxation (OR, 16.3; 95% CI, 3.7 to 96.4), and combativeness (OR, 10.2; 95% CI, 1.5 to 76.8). Successful DAI was associated with the total number of ablated protective reflexes (p < 0.001).

CONCLUSIONS

The ablation of selected and the total number of protective airway reflexes was associated with DAI success. Successful ablation of protective airway reflexes should be considered when attempting to characterize DAI performance or the effectiveness of specific drug facilitation regimens.

Predictors of Intubation Success andTherapeutic Value of Paramedic Airway Management in a Large, Urban EMS System

BACKGROUND

Endotracheal intubation (ETI) is commonly used by paramedics for definitive airway management. The predictors of success and therapeutic value with regard to oxygenation are not well studied.

OBJECTIVES

1) To explore the relationship between intubation success and perfusion status, Glasgow Coma Scale (GCS) score, and end-tidal carbon dioxide (EtCO2); 2) to describe the incidence of unrecognized esophageal intubations with use of continuous capnometry; and 3) to document the incremental benefit of invasive versus noninvasive airway management techniques in correcting hypoxemia.

METHODS

This was a prospective, observational study conducted in a large urban emergency medical services system. Paramedics completed a telephone debriefing interview with quality assurance personnel following delivery of all patients in whom invasive airway management had been attempted. Continuous capnometry was used for confirmation of tube position in all patients. Descriptive statistics were used to document airway management performance, including first-attempt ETI success, overall ETI success, and Combitube insertion (CTI) success. In addition, the incidence of unrecognized esophageal intubation was recorded. The relationship between intubation success and perfusion status, GCS score, and initial EtCO2 value was explored using logistic regression. Finally, recorded SpO2 values and the incidence of hypoxemia (SpO2 < 90%) at baseline, following noninvasive airway maneuvers, and after invasive airway management were compared for perfusing patients.

RESULTS

A total of 703 patients were enrolled over 12 months. First-attempt ETI success was 61%, and overall ETI success was 81%; invasive airway management (ETI or CTI) was unsuccessful in 11% of patients. A single unrecognized esophageal intubation was observed (0.1%). A clear relationship between airway management success and perfusion status, GCS score, and initial EtCO2 value was observed. Only EtCO2 demonstrated an independent association with ETI success after adjusting for the other variables. Significant improvements in mean SpO2 and the incidence of hypoxemia over baseline were observed with both noninvasive and invasive airway management techniques in 168 perfusing patients.

CONCLUSIONS

A relationship between intubation success and perfusion status, GCS score, and initial EtCO2 value was observed. Capnometry was effective in eliminating unrecognized esophageal intubations. Both noninvasive and invasive airway management strategies were effective in increasing SpO2 values and decreasing the incidence of hypoxemia, with additional benefit observed with invasive airway maneuvers in some patients.

Defining the Learning Curve for Paramedic Student Endotracheal Intubation

BACKGROUND

Proficiency in endotracheal intubation (ETI) is assumed to improve primarily with accumulated experience on live patients. While the National Standard Paramedic Curriculum recommends that paramedic students (PSs) perform at least five live ETIs, these training opportunities are limited.

OBJECTIVE

To evaluate the effects of cumulative live ETI experience, elapsed duration of training, and clinical setting on PS ETI proficiency.

METHODS

The authors used longitudinal, multicenter data from 60 paramedic training programs over a two-year period. The PSs reported outcomes (success/failure) for all live ETIs attempted in the operating room (OR), the emergency department (ED), the intensive care unit (ICU), and other hospital or prehospital settings. Fixed-effects logistic regression was used to model up to 30 consecutive ETI efforts by each PS, accounting for per-PS clustering. For each patient, the authors evaluated the association between ETI success and the PS's cumulative number of ETIs, adjusted for clinical setting, elapsed number of days from the first ETI encounter, and the interaction (cumulative ETIs x elapsed days). Predicted probability plots were constructed depicting the "learning curve" overall and for each clinical setting. Results. Between one and 74 ETIs (median 7; IQR 4-12) were performed by each of 802 PSs. Of 7,635 ETIs, 6,464 (87.4%) were successful. Stratified by clinical setting, 6,311 (82.7%) ETIs were performed in the OR, 271 (3.6%) in the ED, 64 (0.8%) in the ICU, 86 (1.1%) in other in-hospital settings, and 903 (11.8%) in the prehospital setting. For the 7,398 ETIs included in the multivariate analysis, cumulative number of ETI was associated with increased adjusted odds of ETI success (odds ratio 1.067 per ETI; 95% CI: 1.044-1.091). ETI learning curves were steepest for the ICU and prehospital settings but lower than for other clinical settings.

CONCLUSIONS

Paramedic student ETI success improves with accumulated live experience but appears to vary across different clinical settings. Strategies for PS airway education must consider the volume of live ETIs as well as the clinical settings used for ETI training.

Ensuring quality in prehospital airway management

PURPOSE OF REVIEW

Ensuring quality in prehospital airway management is challenging because the out-of-hospital setting is a fast-paced and unpredictable environment. The first step in meeting this challenge is the recognition by emergency medical service leaders that prehospital airway management is prone to error. Quality core values such as safety, effectiveness, timeliness, efficiency, and equity for prehospital airway management, specifically endotracheal intubation, will be discussed.

RECENT FINDINGS

Controlled studies in prehospital airway management are few. In those that have evaluated the use of endotracheal intubation in this setting, safety issues, increased scene time, and lack of effectiveness to improve outcome have been revealed.

SUMMARY

Emergency medical service administrators must critically evaluate the quality of prehospital airway management that they are providing to patients within their system by collecting the data necessary to identify quality issues and developing strategies to implement change. Research into other techniques that can provide ventilation and oxygenation to patients in the prehospital environment and that are safe and effective, such as laryngeal mask airway, need to be performed.

Strategien zur Optimierung notärztlicher Kompetenz in der Flugrettung

PURPOSE

Preclinical emergency medical treatment necessitates a comprehensive interdisciplinary knowledge by the emergency physician as well as a high level of manual dexterity. The quality of treatment therefore depends on the level of education and continuous training in emergency medical techniques. Based on an evaluation of the frequency of life-saving interventions by a physician-staffed rescue helicopter system, strategies for in-hospital training of relevant skills are suggested.

MATERIAL AND METHODS

At the outset, 10 important areas of treatment (e.g. intubation, chest tube etc.) and their frequency in emergency medical services were defined as the standard to be attained by emergency physicians within 1 year. The selection of the areas of treatment was based to some extent on international recommendations. The actual frequencies of the prehospital interventions were compared to the required minimum numbers by retrospective analysis of the helicopter rescue database (NACA-X).

RESULTS

During the observation period of 1 year, 20 emergency physicians responded to 956 prehospital emergency calls. A life-threatening condition requiring an on-site intervention occurred in only 521 (54.5%) patients, so that the majority of physicians did not perform the required minimum number of interventions. In order to maintain their level of skill, the emergency physicians were required to undertake additional training at the local university hospital.

CONCLUSION

The frequency of on-site life-saving interventions in emergency medicine is insufficient to fulfill the quota necessary to maintain adequate training of emergency physicians. Only a link-up program at a hospital for primary care can ensure an adequate training level.

The laryngeal tube device: a simple and timely adjunct to airway management

INTRODUCTION

Endotracheal intubation (ETI) is a motor skill that demands practice. Emergency medical service providers with limited intubation experience should consider using airway adjuncts other than ETI for respiratory compromise. Prehospital ETI has been recently interrogated by evidence exposing worsened patient outcomes. The laryngeal tube (LT) airway was approved by the Food and Drug Administration in 2003 for use in the United States. Using difficult airway-simulated models, we sought to describe the time difference between placing the ETI and LT and the successful placement of each adjunct in varied levels of healthcare providers.

METHODS

Emergency medicine resident physicians, fourth year medical students, and paramedic students were asked to use both ETI and the LT. Subjects were timed (seconds) on ETI and LT placement on 2 different simulators (AirMan and SimMan; Laerdal Co, Wappingers Falls, NY). After ETI was complete, they were given 30 seconds to review an instructional card before placement of the LT. We measured placement time and successful placement of the device for ETI vs LT. Successful placement in the manikin was defined by a combination of breath sounds, chest rise, and absence of epigastric sounds.

RESULTS

Overall mean placement time in the AirMan and SimMan for ETI was 76.4 (95% confidence interval [CI], 63.3-89.5) and 45.9 (95% CI, 41.0-50.2) seconds, respectively. Mean placement time for the LT in the AirMan and SimMan was 26.9 (95% CI, 24.3-29.5) and 20.3 (95% CI, 18.1-22.5) seconds, respectively. The time difference between ETI and LT for both simulators was significant (P < .0001). Successful placement of the LT compared with ETI in the AirMan was significant (P = .001).

CONCLUSIONS

A significant time difference and simplicity exists in placing the LT, making it an attractive device for expeditious airway management. Further studies will need to validate the LT effectiveness in ventilation and oxygenation; however, its uncomplicated design allows for successful use by a variety of healthcare providers.

Prehospital standardization of medical airway management: incidence and risk factors of difficult airway

OBJECTIVES

The rate of difficult intubation in prehospital emergency medicine varies greatly among studies already published and depends on several factors. The authors' objective was to determine the rate of difficult intubations and to determine factors associated with prehospital difficult airways when a standard protocol for sedation and intubation was applied.

METHODS

This 30-month clinical, observational, prospective study was performed in a suburb of Paris, France (Val de Marne, population 1,300,000) by a prehospital emergency medical unit. Airway management for patients who needed tracheal intubation was standardized. The pharmacological procedure recommended rapid sequence intubation for patients with spontaneous cardiac activity. In cases of difficult, laryngoscopy-assisted intubation, a predefined algorithm was proposed. The Intubation Difficulty Score (IDS) was calculated for all patients requiring tracheal intubation, and factors associated with difficult intubation, defined by IDS of >5, were identified by using multivariate statistical analysis.

RESULTS

During the study period, 1,442 patients were included; 640 (44%) were in cardiorespiratory arrest, and 802 had a spontaneous cardiac activity. Deviation from the pharmacological and airway management procedures occurred in 1% of cases. When the predefined difficult airway management algorithm was followed, failure to intubate was encountered twice (0.1%). One hundred six (7.4%) patients had an IDS of >5, and 60 (4.1%) required first (n = 56) then second (n = 4) alternative techniques for tracheal intubation. Semirigid leaders allowed tracheal access in 93% of difficult-intubation patients. One patient required a prehospital cricothyroidotomy. Factors associated with difficult intubation were the following: a history of ear, nose, or throat neoplasia or surgery; obesity; facial trauma; the operator's status; and the operator's position.

CONCLUSIONS

If prehospital medical airway management is standardized and performed by trained operators, failure to intubate is rare (0.1%), and the incidence of difficult tracheal intubation is 7.4%, independent of cardiorespiratory status.

How many attempts are required to accomplish out-of-hospital endotracheal intubation?

BACKGROUND

An important goal of emergency airway management is to complete endotracheal intubation (ETI) correctly, safely, and quickly, and repeated ETI attempts can increase patient morbidity and mortality. Clinical protocols limiting the number of ETI attempts may minimize harm, but this strategy also may reduce the frequency of successful ETI.

OBJECTIVES

To characterize the relationship between the number of out-of-hospital ETI attempts and ETI success.

METHODS

This study used prospective, multicenter data from 42 emergency medical services agencies from an 18-month period. Out-of-hospital rescuers (paramedics, out-of-hospital nurses, and physicians) completed structured, closed-response data forms describing clinical methods, course, and outcomes for all ETIs. An ETI attempt was defined as an insertion of the laryngoscope blade. Rescuers identified ETI outcome (success or failure) for each attempt. The authors defined overall success as ETI outcome (success or failure) on the last attempt, examining cardiac arrest, conventional nonarrest, sedation-facilitated, and rapid-sequence ETI separately. Univariate odds ratios (ORs) were used to identify the number of ETI attempts in which the cumulative ETI success rate approached the overall ETI success rate.

RESULTS

Complete data were available for 1,941 cases. More than 30% of patients received more than one ETI attempt. For 1,272 cardiac arrest ETIs, cumulative success for the first three attempts were 69.9%, 84.9%, and 89.9%; cumulative success approached overall success (91.8%) after three attempts (OR, 0.79; 95% confidence interval [CI] = 0.61 to 1.04). For 463 conventional non-arrest ETIs, cumulative success for the first three attempts were 57.6%, 69.2%, and 72.7%; cumulative success approached overall success (73.7%) after two attempts (OR, 0.95; 95% CI = 0.71 to 1.28). For 126 sedation-facilitated ETIs, cumulative success for the first three attempts were 44.4%, 62.7%, and 75.4%; cumulative success approached overall success (77.0%) after three attempts (OR, 0.92; 95% CI = 0.51 to 1.64). For 80 rapid-sequence ETI, cumulative ETI success for the first three attempts were 56.3%, 81.3%, and 91.3%; cumulative success approached overall success (96.3%) after three attempts (OR, 0.41; 95% CI = 0.10 to 1.65).

CONCLUSIONS

Out-of-hospital rescuers often require multiple attempts to accomplish ETI. A protocol limit of three attempts offers reasonable opportunity for accomplishing ETI within the constraints of the out-of-hospital environment.

Procedural experience with out-of-hospital endotracheal intubation

OBJECTIVE

Out-of-hospital rescuers likely need regular clinical experience to perform endotracheal intubation (ETI) in a safe and effective manner. We sought to determine the frequency of ETI performed by individual out-of-hospital rescuers.

DESIGN

Analysis of an administrative database of all emergency medical services (EMS) patient care reports in Pennsylvania.

SETTING

Commonwealth of Pennsylvania from January 1 to December 31, 2003.

SUBJECTS

EMS advanced life support rescuers (paramedics, prehospital nurses, and EMS physicians) who reported at least one patient contact during the study period.

INTERVENTIONS

None.

MEASUREMENTS

We calculated individual rescuer ETI frequency and opportunity. We evaluated relationships between ETI frequency and the number of patient contacts. We also examined the relationship with practice setting (air medical vs. ground rescuers and urban vs. rural rescuers).

MAIN RESULTS

In 1,544,791 patient care reports, 11,484 ETIs were reported by 5,245 out-of-hospital rescuers. The median ETI frequency was one (interquartile range, 0-3; range, 0-23). Of 5,245 rescuers, >67% (3,551) performed two or fewer ETIs, and >39% (2,054) rescuers did not perform any ETIs. The median number of ETI opportunities was three (interquartile range, 0-6; range, 0-76). ETI frequency was associated with patient volume (Spearman's rho = 0.67) and was higher for air medical (p = .006) and urban (p < .0001) rescuers. ETI frequency was not associated with response (Spearman's rho = -0.01) or transport (Spearman's rho = -0.06) times.

CONCLUSIONS

Out-of-hospital ETI, an important and difficult resuscitation intervention, is an uncommon event for most rescuers.

A retrospective analysis of the intubations performed during 5 years of helicopter emergency medical service in Amsterdam

INTRODUCTION

Different skilled personnel perform prehospital airway management, by far one of the most challenging skills with major consequences upon failure.

SETTING

The setting for this study was the helicopter emergency medical service at the Vrije Universiteit Medical Center, Amsterdam, the Netherlands.

METHODS

We conducted a retrospective analysis of all medical charts of intubated trauma patients in the period from May 1995 to May 2000. We focused on intubation reasons and conditions.

RESULTS

In 43 of 653 patients (7%) the process of intubation was recorded as being difficult, leading to 5 failed intubations (11.6%). In 432 of 653 trauma victims (66%), general anaesthesia was required before intubation. Forty (9%) of these patients died, most soon after arrival in the hospital. The clinical condition of 221 (34%) patients was so poor that they did not require additional drugs for intubation; 73% of those patients died, with two-thirds dying at the accident site.

CONCLUSION

The rate of difficult intubation in this analysis is low (7%). The overall airway failure (11.6%) is the same as seen in the literature when sedation and relaxation are used. An adult trauma victim with a Revised Trauma Score of 0 has a very poor prognosis of survival.

[Prehospital emergency airway management procedures. Success rates and complications]

BACKGROUND

Oxygenation and ventilation as well as prevention of aspiration are of vital importance for emergency patients. Prehospital airway management is not comparable to clinical anaesthesia. However, prehospital data of the occurrence of potential life-threatening complications and less severe adverse events of airway management procedures by emergency physicians are not yet available.

METHODS

All airway management procedures predominantly performed by emergency physicians over a period of 36 months were recorded prospectively.

RESULTS

Data of 598 consecutive patients were collected, in all patients prehospital airway management could be accomplished successfully. Of the patients 98.5% were successfully intubated endotracheally with a maximum of 3 attempts, 84.6% of patients were intubated at the first attempt, and in 9 patients other techniques such as the Combitube were required. In more than 80% of procedures, no complications or adverse events were recorded and potentially life-threatening complications occurred in 9% of patients only.

CONCLUSIONS

Prehospital airway management by emergency physicians experienced in anaesthesia is associated with low complication and high success rates.

Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation

STUDY OBJECTIVE

Previous out-of-hospital airway management data are limited by small, single-site designs. We sought to evaluate the feasibility of performing a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation (ETI) using a standardized data collection tool.

METHODS

We designed a prospective multi-centered observational study involving 45 advanced life support (ALS) services from a mid-Atlantic state. Using a standardized data form, prehospital personnel reported details of each attempted ETI, including patient demographics, methods used, difficulties encountered, and initial patient outcomes. We calculated and assessed data form return rates (using independent queries of the number of ETI attempted by each EMS service) and missing data entry rates. We also performed preliminary cross-sectional assessments of factors of current interest in out-of-hospital ETI. Accuracy and validity of responses were not evaluated. Data were stored centrally and analyzed using descriptive techniques.

RESULTS

Participants included 8 urban, 15 suburban, 20 rural, and 2 air medical services. Data forms were received on 783 adults receiving ETI attempts during the study period June 1, 2001-November 30, 2001. The pooled data form return rate was 72.7%. Per-service return rates ranged from 0 to 100% and the median per-service return rate was 75%. Non-response (data form not returned for attempted intubation) was problematic, with nine services demonstrating data return rates less than 50%. Data return rates could not be calculated for an additional nine services. The missing data entry rate was 0.5-22.2%. The overall reported ETI success rate was 86.8% (92.8% for cardiac arrests and 76.8% for non-arrests) and did not appear to vary between population settings. There were two cases of delayed recognition of esophageal intubation, one case of unrecognized esophageal intubation, and 22 cases of tube dislodgement during patient care or transport. Bag-valve-mask ventilation was used as the rescue airway technique in the majority of failed ETI. When stratified for cardiac arrests vs. non-arrests, ETI success was not associated with field or initial ED survival.

CONCLUSIONS

We successfully obtained complete data for the majority of ETI attempted across multiple EMS services. Our data also indicate the need to address problems with non-response. Preliminary cross-sectional data highlight areas of current interest in out-of-hospital airway management.

Comparison of times to intubate a simulated trauma patient in two positions

BACKGROUND

The nature of the trauma patient's injuries may compromise the airway and ultimately lead to death or neurological devastation. The same injuries complicate protecting the airway in these patients by preventing manipulation of the cervical spine for direct laryngoscopy. A recent study has shown that misplaced endotracheal tubes occur significantly more often in trauma patients than in medical patients.

OBJECTIVES

The authors hypothesized that elevating the long spine board would reduce the amount of time required for paramedics to intubate a simulated trauma patient.

METHODS

Paramedics from an urban emergency medical services division were given up to two opportunities to intubate a manikin in a type I ambulance in each of two positions in random order: supine and with the head elevated. The manikin was secured to a long spine board with three straps, a semi-rigid cervical collar, and a cervical immobilization device. An investigator maintained cervical spine alignment and provided cricoid pressure. The elevated position was accomplished by raising the head of the stretcher 27 degrees, resulting in 7 degrees of spine board elevation. Each attempt was timed. If the first attempt was unsuccessful, the times for both the first and second attempts were totaled to determine the total time required for intubation. Times for successful intubation in each position were compared with a Mann-Whitney test. First-attempt success rates for each position were compared with chi2 analysis. Multinomial regression was used to determine whether experience, paramedic height, or previous intubation success influenced intubation time in either position.

RESULTS

Fifty-five paramedics provided informed consent and completed the study. Average time to intubate the supine manikin was significantly longer than needed to intubate the head-elevated manikin (35.6 +/- 19.0 seconds vs 27.9 +/- 12.8 seconds, p = 0.025). The manikin was successfully intubated on the first attempt 84% in the supine position and 95% in the head-elevated position (p = 0.200). Regression analysis identified intubation position as the only significant predictor of intubation time (p = 0.007).

CONCLUSIONS

Modest elevation of the head of an immobilized patient appears to allow more rapid intubation. With the spine board properly secured to the stretcher, this technique potentially offers improved intubation time without additional cost or equipment.

Eliminating errors in emergency medical services: realities and recommendations

Errors in health care can have serious consequences, not only for patients but for society as a whole, given the considerable national expenditures required to address these errors. Because of the number of patients treated and the acuity of emergency situations, eliminating errors should be a priority in emergency medical services (EMS) systems. In a recent report, the Institute of Medicine called for improvements in patient safety, which it defined as freedom from accidental injury. Recent efforts have focused on integrating EMS systems into error analyses of the total health care system. However, EMS systems must take the initiative in addressing their own major error-prone areas using the best and most current data available. Unfortunately, addressing the problem of medical errors in EMS systems still suffers from a paucity of data, owing to a lack of organized, funded programs backed by legislation and dedicated government coordination. We recommend that EMS medical directors consider specific error audits to decrease sources of errors and to be better able to identify EMS providers who would benefit from retraining. Error audits might first be focused on the following potentially serious errors: equipment malfunction, failure to check oxygen saturation, failure to immobilize the patient, use of incorrect protocol or algorithm, failure to check glucose levels, failure to recognize patient deterioration, failure to detect misplaced endotracheal tubes, and use of wrong drug or drug dose.