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1 s2.0 S0736467903001987 Mainemt - Med
1 s2.0 S0736467903001987 Mainemt - Med
251–256, 2003
Copyright © 2003 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/03 $–see front matter
doi:10.1016/S0736-4679(03)00198-7
Original
Contributions
e Abstract—This study’s objective was to determine the cant correlation with intubation success rate. © 2003
effect of paramedic experience on orotracheal intubation Elsevier Inc.
success in prehospital adult nontraumatic cardiac arrest
patients. This retrospective study analyzed all attempted e Keywords— emergency medical services; intubation;
intubations of prehospital adult nontraumatic cardiac ar- airway; paramedic; cardiac arrest
rest patients between January 1, 1997 and April 30, 1997 in
an urban, all ALS service. Data were abstracted from EMS
reports and intubation data forms. Variables included INTRODUCTION
months of experience, number of patients in whom intuba-
tion was attempted, number of intubation attempts, success
Paramedics have consistently demonstrated to the med-
per attempt, and success per patient. Ninety-eight para-
medics performed 909 intubations on 1066 cardiac arrest
ical community that they can perform endotracheal intu-
patients, yielding an intubation success rate of 85.3%. The bation with good success rates (1–3). Orotracheal intu-
median months of experience was 59.5 (Range 5–223). The bation is now considered the cornerstone skill of
median number of patients in whom intubation was at- advanced airway management for paramedics. For Emer-
tempted per paramedic was 10 (Range 1–36). The mean gency Medical Services (EMS) medical directors, assess-
intubation success rate per paramedic was 80.6% (ⴞ 22.4, ing the intubation ability of their paramedics is a critical
95% CI 76.1, 85.1). There was significant correlation be- component of their position. Previous studies have dem-
tween total number of patients in whom intubation was onstrated that cardiac arrest survival rates are generally
attempted and intubation success rate (p < .001, R ⴝ 0.32). lower in communities where paramedics are not allowed
There was no correlation between months of experience to intubate (4 – 6). Improved outcomes for trauma pa-
and intubation success rate. In conclusion, the number of
tients who were intubated in the field also have been
patients in whom intubation was attempted per paramedic
was significantly correlated with the intubation success
previously published (7–9). Additionally, intubation suc-
rate. Months of experience per paramedic had no signifi- cess rate is one of the more objective measures that
medical directors can use to monitor the quality of their
EMS systems (10,11).
Presented at the NAEMSP Annual Meeting in Ft. Myers, FL Intuitively, health care providers have assumed that
in January 2001. more experienced paramedics should be able to perform
orotracheal intubation with greater success than less ex- Paramedics were excluded from the study if their
perienced paramedics. Few previous studies, however, primary role was anything other than a field paramedic
have examined whether this experience is a measure of (e.g., dispatchers, administrative personnel, and field su-
seniority or the frequency of skill usage. The EMS lit- pervisors). Paramedics were also excluded if they did not
erature yields conflicting results on the relationship be- work in the system during the entire study period. For
tween paramedic experience and intubation success each paramedic, months of experience was defined by
(2,12,13). calculating the date that the paramedic was first state
The primary objective of this study was to determine licensed to the starting date of this study; this time
if there was any correlation between paramedic experi- included any prior employment in other EMS systems
ence and orotracheal intubation success in out-of-hospi- and any evaluation or probationary time.
tal nontraumatic cardiac arrest patients. Data were entered into a database (Microsoft Ac-
cess™, Redmond, WA) and analyzed using SPSS 10.0
(SPSS™ Chicago, IL) statistical software. Intubation
MATERIALS AND METHODS data between January 1, 1997 and April 30, 1999 (28
months) were analyzed. Descriptive statistics were per-
This retrospective study was conducted in a midwestern, formed on months of experience, number of patients in
urban EMS system. The initial responders were Emer- whom intubation was attempted, number of attempts,
gency Medical Technicians (EMTs) and First Respond- success per attempt, and success per patient. Pearson
ers from the local Fire Department. The Fire Department correlation was performed comparing the paramedic’s
responded to all cardiac arrest calls and was equipped intubation success rate with months of experience and
with Automated External Defibrillators. The ambulance the success rate with the number of patients in whom
system is a single tier, all Advanced Life Support (ALS), intubation was attempted per paramedic. A p value of ⬍
public utility model service providing exclusive emer- .05 was considered significant.
gency and nonemergency care and transport within the The University of Missouri—Kansas City Adult
city limits. During the study period, the ambulance ser- Health Sciences Institutional Review Board exempted
vice transported over 60,000 patients per year and was this study from review.
staffed using a split crew of EMT/Driver and a single
Paramedic/Attendant. Paramedics in this system are li-
censed by the City Health Department, the State Bureau
of Emergency Medical Services, and have National Reg- RESULTS
istry certification.
Medical oversight of the system was performed by the During the study period, 98 paramedics attempted to
City Health Department’s EMS Section. This section and intubate a total of 1345 cardiac arrest patients. There
the Quality Improvement (QI) Manager for the ambu- were 1105 adult, nontraumatic cardiac arrests during the
lance service routinely collect data on all attempted in- study period (82.2%), of which 1066 (96.5%) met inclu-
tubations. sion criteria. Thirty-three cardiac arrest patients had in-
Inclusion criteria included all adult medical cardiac tubations performed by paramedics that did not fit inclu-
arrest patients intubated by full-time paramedic field sion criteria (i.e., not full-time field personnel). Six
personnel between January 1, 1997 and April 30, 1999. cardiac arrest patients (0.6%) did not have an intubation
Intubation data for every adult (age ⬎ 15 years) attempt performed. Of the 1066 study patients, 909 were
nontraumatic cardiac arrest patient were extracted by the successfully intubated, yielding an overall intubation
QI Manager from state ambulance report forms and success rate of 85.3%.
intubation data sheets completed by the treating para- The paramedic study population had a median of 59.5
medic. The receiving Emergency Physician signed the months of experience (Range 5–223) (Figure 1). During
intubation data sheet verifying endotracheal tube place- the study period, there was a median of 10 patients in
ment. An orotracheal intubation attempt was defined as whom intubation was attempted per paramedic (Range
any time the laryngoscope blade was advanced past the 1–36) (Figure 2). The average number of intubation
teeth in an attempt to intubate the patient. The EMS attempts per paramedic was 1.3 (Range 1.0 –2.75). The
system allowed nasotracheal intubation for certain pop- mean intubation success rate per paramedic was 80.6 (⫾
ulations of patients, none of whom were included in this 22.3; 95% CI 76.1, 85.1) (Figure 3).
study. The system uses ETCO2 detectors; however, there There was a significant correlation between the total
were no esophageal detection devices used during the number of patients in whom intubation was attempted
study period. Rapid sequence intubations are not per- per paramedic and intubation success (p ⬍ .001, R ⫽
formed. 0.324) (Figure 4). There was no significant correlation
Paramedic Experience and Intubation Success 253
Figure 1. Months of experience for paramedic study popu- Figure 3. Mean intubation success rate per paramedic.
lation.
results of our study, it could be argued that having too study period, there were no ongoing continuous quality
many ALS providers in a system may actually be detri- insurance projects for airway management in the EMS
mental to maintaining sufficient skill levels if an active system that could have confounded the intubation suc-
training program is not in place. Without adequate con- cess rates.
tinuous airway training and quality assurance, the poten- The results of this study cannot be extrapolated to
tial exists to create a spectrum containing a few para- provide a basis for initial airway training or intubation
medics who intubate frequently with resultant good maintenance programs. However, absent a program for
success rates and many paramedics who intubate infre- maintaining intubation performance, a policy of having a
quently but with inadequate success rates (15). Kovacs et certain number of intubations per year by some EMS
al. found that continuous training made a significant systems may indeed be a valid argument to ensure skill
difference in intubation skill retention using a random- maintenance (3,18,19).
ized controlled trial of educational interventions among
non-EMS providers (16). Furthermore, Stewart et al.
found no clear advantage of training paramedics to intu- CONCLUSIONS
bate in the operating room (OR), compared to manikin
training, suggesting that the ability to maintain skill In this study, there was a significant correlation between
proficiency may not be very burdensome (2). the number of patients in whom intubation was at-
Equally as important is the necessity to track intuba- tempted and orotracheal intubation success for adult non-
tion proficiency within the EMS system. In an example traumatic cardiac arrest patients. No significant correla-
of how patient care is compromised by lack of quality tion was found between months of experience and
controls, Katz and Falk detailed a large percentage of intubation success.
unrecognized esophageal intubations in Orange County, Future research should include a prospective design to
Florida. The authors argued that the primary causes of account for paramedic education, intubation complica-
this were nonexistent quality control, poor medical over- tions, and whether routinely scheduled intubation train-
sight, and lack of continuing education within multiple ing alters the correlation between skill use frequency and
EMS services in the region (17). The esophageal intuba- intubation success.
tion rate for our study was 0.66 per 100 patients (or one
unrecognized esophageal intubation per 151 patients in-
tubated).
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