Abstract 310: Disparities Between Reported And Actual First Pass Discovered After Video Review Of Prehospital Intubations

Abstract

Purpose: Often emphasized as a best practice in prehospital airway management, first-pass intubation success (FPS) depends upon paramedic self-reports. We sought to determine the accuracy of paramedic reports of FPS in prehospital airway management. Methods: We analyzed adult (age >=18 years) prehospital airway management data from a ground EMS agency, including cases from 5/1/2020 to 2/28/2022. Paramedics performed all adult prehospital endotracheal intubations (ETI) using standard video laryngoscopy (Airtraq, Mountain View CA) with a hyperangulated blade. Paramedics did not use neuromuscular blocking agents for ETI. Real time video images were recorded for all cases. We excluded cases where the video was missing, data was not captured, or the video was of insufficient quality. Each video was reviewed by a single independent rater using the same objective definition of FPS as the paramedic. The primary outcome was FPS, defined as correct intratracheal placement on the first video laryngoscopy. We evaluated agreement between paramedic and reviewer-reported FPS using Cohen’s Kappa statistic. Results: There were a total of 514 ETI cases, including cardiac arrest, trauma, and non-arrest medical. Paramedic and reviewer reported FPS agreed in 429/514 (83.5%) and disagreed in 85 (16.5%). Of the discordant cases, the paramedic reported FPS but the reviewer disagreed in 78 (92%). Interrater agreement was strong; kappa 0.659 (95%CI 0.595 - 0.722). FPS discordance was not associated with patient age, sex, cardiac arrest status. Conclusions: Despite the computed Kappa statistic showing strong interrater reliability, the objective nature of the rating leaves very little room for discordance. The expected result would have been near compete agreement, however 15% of cases resulted in disagreement. Additionally, when there was disagreement, it overwhelmingly favored the clinician reporting FPS when the reviewer disagreed. Paramedics incorrectly reported FPS in 1 of 6 ETI. Independent review is essential in the assessment of prehospital ETI performance. Further study is needed to determine the reasons for the discordance that may include confusion about the FPS definition or incentivization (real or perceived) of reporting outcomes in a particular way.