Effect of Intensive Physician Oversight on A Prehospital Rapid-Sequence Intubation Program

Abstract

Objective. To examine the effects of adding close concurrent and retrospective physician oversight, consistent with National Association of EMS Physicians (NAEMSP) recommendations, to an existing regional prehospital rapid-sequence intubation (RSI) program. Methods. This study involved a retrospective cohort of patients receiving RSI between January 1, 2004, and July 31, 2008. On January 1, 2007, an updated program including additional concurrent and retrospective physician oversight, increased RSI-specific continuing medical education, and cadaver laboratory training was implemented. Study patients were divided into a preintervention group (group 1) and a postintervention group (group 2) based on date of medical care. Data regarding baseline characteristics, airway management, medication usage, and performance factors were compared between the groups. A retrospective review by two emergency medical services (EMS) physicians assessed whether the RSI was “clearly indicated” based on a predetermined set of criteria. Results. There were 109 RSIs performed in group 1 and 54 in group 2. Absolute increases in the use of both basic life support (BLS) (5%, p = 0.2) and advanced life support (ALS) (41%, p = 0.001) airway techniques were observed. Increases in postintubation administration of midazolam (30%, p = 0.001) and morphine (24%, p = 0.001) and a decrease for vecuronium (–28%, p = 0.001) were observed. There was no statistically significant difference in the intubation success rates (92% vs. 94%) and the frequencies of recognized esophageal endotracheal tube (ETT) placement (5% vs. 6%). The number of unrecognized esophageal ETT placements remained zero. Physician chart review demonstrated an absolute increase in “clearly indicated” RSIs (17%, p = 0.01). Conclusions. Close concurrent and retrospective physician oversight consistent with recommendations from the NAEMSP is associated with improved cognitive skills in paramedics, including appropriate patient selection for RSI. Further research is warranted to validate this model and optimize where resources are best used to enhance patient safety and improve clinical management for this controversial paramedic skill.