Pre-hospital Emergency Anaesthesia Research Articles

Key performance indicators for pre hospital emergency Anaesthesia - a suggested approach for implementation

BackgroundPre-hospital Emergency Anaesthesia (PHEA) is regarded as one of the highest risk interventions that pre-hospital providers perform. AAGBI guidance from 2017 suggests the use of Key Performance Indicators (KPIs) to audit PHEA quality. The aim of this study was to develop KPIs for use in our service and evaluate their impact.MethodsUsing the AAGBI 2017 document as a guide we developed a list of ten auditable domains. Data for each case was extracted from the Electronic Patient Record (EPR) and a score assigned to each of the domains; one if the domain is achieved and zero if the domain is not achieved or if data is missing, giving a total score out of ten. This analysis is then presented as a colour-coded matrix alongside the score. Data were analysed monthly at our case review and governance meeting. The process was refined during the year and after 12 months a formal review of the KPI process occurred.ResultsEighty-two cases were analysed. Domains with the highest percentage of achievement were: Indication 96%; Tube position confirmed 94% and Full AAGBI monitoring and Grade of view < 3 both 89%. The amount of missing data declined throughout the year. The results of the clinician survey showed that almost all respondents found the TVAA PHEA review process useful.ConclusionThe KPI process has demonstrated areas of good quality practice and led to improvements in equipment, processes and documentation and therefore patient care. We offer suggestions to other organisations considering implementing KPIs for PHEA.

A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre-hospital and retrieval medicine.

Airway management is a cornerstone of emergency care. Development of a robust evidence base to support the practice of pre-hospital emergency anaesthesia is key to the safety and evolution of this common but high-risk procedure. This paper discusses the benefits, risks, insights, learning and limitations of the use of an airway registry in pre-hospital and retrieval medicine, for both research and quality improvement purposes.

Best practice advice on pre-hospital emergency anaesthesia & advanced airway management

BackgroundEffective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management.MethodThis best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online.ResultsThis EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice.ConclusionPHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

BackgroundWe examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.MethodsThis study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.ResultsIn total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).ConclusionsPre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists

IntroductionPrehospital emergency anaesthesia (PHEA or ‘prehospital rapid sequence intubation’) is a high-risk procedure. Standard operating procedures (SOPs) and checklists within healthcare systems have been demonstrated to reduce human error and...

Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental?

The benefits of pre-hospital emergency anaesthesia (PHEA) are controversial. Patients who are hypovolaemic prior to induction of anaesthesia are at risk of severe cardiovascular instability post-induction. This study compared mortality for hypovolaemic trauma patients (without major neurological injury) undergoing PHEA with a patient cohort with similar physiology transported to hospital without PHEA. A retrospective database review was performed to identify patients who were hypotensive on scene [systolic blood pressure (SBP) < 90 mmHg], and GCS 13-15. Patient records were reviewed independently by two pre-hospital clinicians to identify the likelihood of hypovolaemia. Primary outcome measure was mortality defined as death before hospital discharge. Two hundred and thirty-six patients were included; 101 patients underwent PHEA. Fifteen PHEA patients died (14.9%) compared with six non-PHEA patients (4.4%), P = 0.01; unadjusted OR for death was 3.73 (1.30-12.21; P = 0.01). This association remained after adjustment for age, injury mechanism, heart rate and hypovolaemia (adjusted odds ratio 3.07 (1.03-9.14) P = 0.04). Fifty-eight PHEA patients (57.4%) were hypovolaemic prior to induction of anaesthesia, 14 died (24%). Of 43 PHEA patients (42.6%) not meeting hypovolaemia criteria, one died (2%); unadjusted OR for mortality was 13.12 (1.84-578.21). After adjustment for age, injury mechanism and initial heart rate, the odds ratio for mortality remained significant at 9.99 (1.69-58.98); P = 0.01. Our results suggest an association between PHEA and in-hospital mortality in awake hypotensive trauma patients, which is strengthened when hypotension is due to hypovolaemia. If patients are hypovolaemic and awake on scene it might, where possible, be appropriate to delay induction of anaesthesia until hospital arrival.

AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland.

SummaryPre‐hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in‐hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in‐hospital anaesthesia standards. Practitioners need to be competent in the provision of in‐hospital emergency anaesthesia and have supervised pre‐hospital experience before carrying out pre‐hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre‐hospital emergency anaesthesia by non‐physicians do not currently exist in the UK. Where pre‐hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second‐generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

Conducting a safe rapid sequence induction in pre-hospital care

This review article will consider how to conduct a safe rapid sequence induction of anaesthesia in the pre-hospital environment. It considers the potential risks and benefits of doing so, reviews some of the literature surrounding the technique and considers aspects from clinician training to choice of induction agent. It aims to give an overview of this element of pre-hospital emergency anaesthesia.

Comparison of factors associated with desaturation in prehospital emergency anaesthesia in primary and secondary retrievals

ObjectiveTo investigate the incidence and factors associated with desaturation related to emergency intubations within an aeromedical retrieval service pertaining to both primary prehospital and secondary interhospital missions.MethodsA retrospective analysis of...

Anaesthesia and pre‐hospital emergency medicine

Major trauma is a leading cause of death and disability in the UK, particularly in the young. Pre-hospital emergency medicine (PHEM) involves provision of immediate medical care to critically ill and injured patients, across all age ranges, often in environments that may be remote and are not only physically challenging but also limited in terms of time and resources. PHEM is now a GMC-recognised subspecialty of anaesthesia or emergency medicine and the first recognised training program in the UK commenced in August 2012. This article discusses subspeciality development in PHEM, the competency based framework for training in PHEM, and the provision of pre-hospital emergency anaesthesia.

A pre-hospital emergency anaesthesia pre-procedure checklist

Pre-hospital emergency anaesthesia (PHEA) is a high-risk activity. Recent guidelines suggest that providers consider using pre-procedure checklists [1]. We applied the principles of checklist development and design to our PHEA practice, developed a pre-anaesthetic checklist and introduced it to our service.

Prehospital advanced airway management for trauma in the United Kingdom: how, when and by whom?

Advanced airway management in the prehospital arena remains controversial. This paper aims to explore some of the evidence and options available and propose a way forward. Options for provision of, and training in, pre-hospital emergency anaesthesia are explored and alternative strategies are discussed. Where classical rapid sequence induction of anaesthesia proves impractical for operational reasons or due to lack of facilities, training opportunities or skills maintenance, a potential ‘silver standard’ is suggested as an alternative.