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.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Little is known about the quality of acute asthma care in emergency departments (EDs) outside of North America.
We evaluated concordance of acute asthma management in Japanese EDs with ...recommendations in the 2007 National Institutes of Health asthma guidelines and investigated whether guideline concordance was associated with risk of hospital admission.
We conducted a multicenter chart review study in 23 EDs across Japan. We identified ED patients aged 18 to 54 years with acute asthma between 2009 and 2011. Concordance with evidence-based guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at patient and ED levels. These scores ranged from 0 to 100.
Among 1380 patients, the median age was 35 years and 11% were hospitalized. Overall guideline concordance score was suboptimal both at the patient level (mean ± SD, 72 ± 14) and ED level (mean ± SD, 72 ± 6). Specifically, asthma care at the patient level was suboptimal in several areas: inhaled anticholinergics in ED (2%), systemic corticosteroid in ED (56%) and at discharge (36%), and peak flow assessment (9%). A multivariable model that adjusted for severity at presentation and several ED characteristics showed that higher guideline concordance was associated with significantly lower risk of hospital admission (odds ratio, 0.70 per 10-unit increase in composite score; 95% CI, 0.62-0.79 per 10-unit increase in composite score).
The management of acute asthma in Japanese EDs is suboptimal. Greater concordance with guideline-recommended management might reduce unnecessary hospitalizations. Knowledge translation initiatives are warranted to increase adherence with best practice in acute asthma management.
