Publications

BACKGROUND: Although the number of elderly increases disproportionately throughout the industrialised nations and intubation-related cardiovascular compromise is associated with hospital mortality, no emergency medicine literature has reported the direction and magnitude of effect of advanced age on post-intubation hypotension. We seek to determine whether advanced age is associated with an increased rate of hypotension at airway management in emergency departments (EDs).

METHODS: We conducted an analysis of a multi-centre prospective observational study of 13 Japanese EDs from April 2010 to March 2012. Inclusion criteria were all adult non-cardiac-arrest patients who underwent emergency intubation. We excluded patients in whom airway management was performed for shock or status asthmaticus as the principal indication. Patients were divided into two groups defined a priori: age ≥ 65 years old (elderly group) and age < 65 years old (younger group). The primary outcome measure was post-intubation hypotension in the ED.

RESULTS: During the 24-month period, 4,043 subjects required emergency airway management at 13 EDs. Among these, the database recorded 3,872 intubations (capture rate 96%). Of 1,903 eligible patients, 975 patients were age ≥ 65 years (51%) and 928 patients were age < 65 years (49%). The elderly group had a significantly higher rate of post-intubation hypotension compared with the younger group [3% vs. 1%; unadjusted OR 2.7 (95% CI, 1.3-5.6); P = 0.005]. In a model controlling for potential confounders (sex, principal indication, method, medication used to intubate, multiple intubation attempts), advanced age had an adjusted OR for post-intubation hypotension of 2.6 (95% CI, 1.3-5.6; P = 0.01).

CONCLUSIONS: In this large multi-centre study of ED patients who underwent emergent airway management, we found that elderly patients have a significantly higher risk of post-intubation hypotension. These data provide implications for the education and practice of ED airway management that may lead to better clinical outcomes and improved patient safety.

OBJECTIVES: There is little information on geriatric emergency airway management. We sought to describe intubation practices and outcomes for emergency department (ED) geriatric and younger patients in Japan.

METHOD: We formed the Japanese Emergency Airway Network, a consortium of 11 medical centers, and prospectively collected data on ED intubations between 2010 and 2011. All patients 18 years or older who underwent emergent airway management were included in our study. Patients were divided to into 2 groups: 18 to 64-year olds and 65 years or older. We present descriptive data as proportions with 95% confidence intervals (CI).

RESULTS: The database recorded 3277 patients (capture rate 96%), and 3178 met the inclusion criteria. Of 3178 patients, 1844 (58%) were 65 years or older, 1334 (42%) were 18 to 64 years old, 809 (25%) were 80 years or older, and 407 (50%) of them were in the state of cardiac arrest. The geriatric group, compared to the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference 7%; 95% CI 4%-10%;) and in 2 attempts (90% vs 88%; difference 3%; 95% CI 1%-5%) or less. There was no significant difference in the adverse event rates by age group (difference 0%; 95% CI -2% to 3%).

CONCLUSION: In our multicenter study involving a large geriatric population, we found that geriatric patients were intubated with a higher success rate, compared to younger patients. These data provide implications for the geriatric ED airway practice that may lead to better patient-centered emergency care.

OBJECTIVE: This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications.

METHODS: A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed.

RESULTS: The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs.

CONCLUSION: The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy.

BACKGROUND: The recent availability of low-cost tablet computers can facilitate bedside information retrieval by clinicians.

OBJECTIVE: To evaluate the effect of physician tablet use in the Emergency Department.

DESIGN: Prospective cohort study comparing physician workstation usage with and without a tablet.

SETTING: 55,000 visits/year Level 1 Emergency Department at a tertiary academic teaching hospital.

PARTICIPANTS: 13 emergency physicians (7 Attendings, 4 EM3s, and 2 EM1s) worked a total of 168 scheduled shifts (130 without and 38 with tablets) during the study period.

INTERVENTION: Physician use of a tablet computer while delivering direct patient care in the Emergency Department.

MAIN OUTCOME MEASURES: The primary outcome measure was the time spent using the Emergency Department Information System (EDIS) at a computer workstation per shift. The secondary outcome measure was the number of EDIS logins at a computer workstation per shift.

RESULTS: Clinician use of a tablet was associated with a 38min (17-59) decrease in time spent per shift using the EDIS at a computer workstation (p<0.001) after adjusting for clinical role, location, and shift length. The number of logins was also associated with a 5-login (2.2-7.9) decrease per shift (p<0.001) after adjusting for other covariates.

CONCLUSION: Clinical use of a tablet computer was associated with a reduction in the number of times physicians logged into a computer workstation and a reduction in the amount of time they spent there using the EDIS. The presumed benefit is that decreasing time at a computer workstation increases physician availability at the bedside. However, this association will require further investigation.

INTRODUCTION: Mobile health (mHealth) technology can play a critical role in improving disaster victim tracking, triage, patient care, facility management, and theater-wide decision-making.

PROBLEM: To date, no disaster mHealth application provides responders with adequate capabilities to function in an austere environment.

METHODS: The Operational Medicine Institute (OMI) conducted a qualitative trial of a modified version of the off-the-shelf application iChart at the Fond Parisien Disaster Rescue Camp during the large-scale response to the January 12, 2010 earthquake in Haiti.

RESULTS: The iChart mHealth system created a patient log of 617 unique entries used by on-the-ground medical providers and field hospital administrators to facilitate provider triage, improve provider handoffs, and track vulnerable populations such as unaccompanied minors, pregnant women, traumatic orthopedic injuries and specified infectious diseases.

CONCLUSION: The trial demonstrated that even a non-disaster specific application with significant programmatic limitations was an improvement over existing patient tracking and facility management systems. A unified electronic medical record and patient tracking system would add significant value to first responder capabilities in the disaster response setting.

OBJECTIVE: To characterize tracheal intubation process of care and safety outcomes in a large tertiary pediatric intensive care unit using a pediatric adaptation of the National Emergency Airway Registry. Variances in process of care and safety outcome of intubation in the pediatric intensive care unit have not been described. We hypothesize that tracheal intubation is a common but high-risk procedure and that the novel pediatric adaptation of the National Emergency Airway Registry is a feasible tool to capture variances in process of care and outcomes.

DESIGN: Prospective descriptive study.

SETTING: A single 45-bed tertiary noncardiac pediatric intensive care unit in a large university-affiliated children's hospital.

PATIENTS: Critically ill children who required intubation in the pediatric intensive care unit.

INTERVENTIONS: Airway management data were prospectively collected for all initial airway management from July 2007 through September 2008 using the National Emergency Airway Registry tool tailored for pediatric application with explicit operational definitions.

MEASUREMENT AND MAIN RESULTS: One hundred ninety-seven initial intubation encounters were reported (averaging one every 2.3 days). The first course intubation method was oral intubation in 181 (91.9%) and nasal in 16 (9.1%). Unwanted tracheal intubation-associated events were frequently reported (n = 38 [19.3%]), but severe tracheal intubation-associated events were rare (n = 6 [3.0%]). Esophageal intubation with immediate recognition was the most common tracheal intubation-associated event (n = 22). Desaturation <80% was reported in 51 of 183 (27.7%) and more than two intubation attempts in 30 of 196 (15.3%), both associated with occurrence of a tracheal intubation-associated event (p < .001, p = .001, respectively). Interestingly, patient age, history of difficult airway, and first attempt by resident were not associated with tracheal intubation-associated events.

CONCLUSIONS: Unwanted tracheal intubation-associated events occurred frequently, but severe tracheal intubation-associated events were rare. Our novel registry can be used to describe the pediatric intensive care unit tracheal intubation procedural process of care and safety outcomes.

STUDY OBJECTIVE: Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events.

METHODS: We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation.

RESULTS: Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1).

CONCLUSION: In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.

OBJECTIVE: To develop a scoring system that can assess the multidisciplinary management of respiratory failure in a pediatric ICU.

METHODS: In a single tertiary pediatric ICU we conducted a simulation-based evaluation in a patient care area auxiliary to the ICU. The subjects were pediatric and emergency medicine residents, nurses, and respiratory therapists who work in the pediatric ICU. A multidisciplinary focus group with experienced providers in pediatric ICU airway management and patient safety specialists was formed. A task-based scoring instrument was developed to evaluate a primary airway provider's performance through Healthcare Failure Mode and Effect Analysis. Reliability and validity of the instrument were evaluated using multidisciplinary simulation-based airway management training sessions. Each session was evaluated by 3 independent expert raters. A global assessment of the team performance and the previous experience in training were used to evaluate the validity of the instrument.

RESULTS: The Just-in-Time Pediatric Airway Provider Performance Scale (JIT-PAPPS) version 3, with 34 task-based items (14 technical, 20 behavioral), was developed. Eighty-five teams led by resident airway providers were evaluated by 3 raters. The intraclass correlation coefficient for raters was 0.64. The JIT-PAPPS score correlated well with the global rating scale (r = 0.71, P < .001). Mean total scores across the teams were positively associated with resident previous training participation (β coefficient 7.1 ± 0.9, P < .001), suggesting good validity of the scale.

CONCLUSIONS: A task-based scoring instrument for a primary airway provider's performance with a multidisciplinary pediatric ICU team on simulated pediatric respiratory failure was developed. Reliability and validity evaluation supports the developed scale.

With the 2010 federal health care reform passage, a renewed focus has emerged for the integration of electronic health records (EHRs) into the U.S. health care system. A consensus conference in October 2009 met to discuss the future research agenda with regard to using information technology (IT) to improve the future quality and safety of emergency department (ED) care. The literature is mixed as to how the use of computerized provider order entry (CPOE), clinical decision support (CDS), EHRs, and patient tracking systems has improved or degraded the safety and quality of ED care. Such mixed findings must be considered in the national push for rapid implementation of health IT. We present a research agenda addressing the major questions that are posed by the introduction of IT into ED care; these questions relate to interoperability, patient flow and integration into clinical work, real-time decision support, handoffs, safety-critical computing, and the interaction between IT systems and clinical workflows.

OBJECTIVE: To describe the current practice of pediatric airway management at referring hospitals and the associated adverse events compared to a receiving tertiary pediatric ICU.

METHOD: Retrospective chart and transport record review of all emergency critical care transports to our Pediatric ICU over 3 years. Data regarding tracheal intubation procedure, pre-defined adverse Tracheal Intubation Associated Events (TIAEs), and airway events before, during, and after the inter-hospital transport were collected using a standard National Emergency Airway Registry for children (NEAR4KIDS) definition. Tracheal intubation outcomes were compared to in-hospital P ICU intubations.

RESULTS: 253/1489 (17%) of critical care transports had airway management, all by tracheal intubation. The most common condition was seizure (34%), followed by pulmonary/lower airway disease (16%). 49 (19%) had TIAEs; the most common event was mainstem bronchial intubation (13%). Incidence of TIAEs was similar to PICU (p=0.69). Thirteen had an inappropriate tracheal tube position upon PICU arrival, but none experienced accidental extubation during transport. An uncuffed tracheal tube was used in 108/172 (63%) of patients<8 years, significantly higher than PICU (20%, p<0.0001). 124 (49%) were extubated within 24 h, 153 (60%) within 48 h. Two patients had the tracheal tube changed to cuffed from uncuffed due to air leak.

CONCLUSION: Provider reported adverse TIAEs are common during airway management in children requiring critical care transport, but not higher compared to PICU intubations. Most inter-hospital transport patients are intubated with an uncuffed tracheal tube. Subsequent tracheal tube change from uncuffed to cuffed tube is rarely required.