Prehospital advanced airway management by ambulance technicians ...

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technicians and paramedics. Despite prehospital airway management being generally more challenging than that practised in the hospital, the training required ...

Prehospital care

Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills? C D Deakin,1 P King,2 F Thompson1 1

South Central Ambulance Service NHS Trust (Hampshire Division), Otterbourne, UK; 2 Performance Information Team, South Central Ambulance Service NHS Trust (Hampshire Division), Otterbourne, UK Correspondence to: Dr Charles D Deakin, South Central Ambulance Service NHS Trust, Southern House, Sparrowgrove, Otterbourne, Hampshire, SO21 2RU, UK; [email protected] Accepted 22 January 2009

ABSTRACT Introduction: Ambulance paramedics are now trained routinely in advanced airway skills, including tracheal intubation. Initial training in this skill requires the insertion of 25 tracheal tubes, and further ongoing training is attained through clinical practice and manikin-based practice. In contrast, training standards for hospital-based practitioners are considerably greater, requiring approximately 200 tracheal intubations before practice is unsupervised. With debate growing regarding the efficacy of paramedic intubation, there is a need to assess current paramedic airway practice in order to review whether initial training and maintenance of skills provide an acceptable level of competence with which to practice advanced airway skills. Methods: All ambulance patient report forms (anonymised) for the period 1 January 2007 to 31 December 2007 were reviewed, and data relating to airway management were collected. Paramedic and technician identification codes were used to determine the number of airway procedures undertaken on an individual basis. Results: Of the 269 paramedics, 128 (47.6%) had undertaken no intubation and 204 (75.8%) had undertaken one or less intubation in the 12-month study period. The median number of intubations per paramedic during the 12-month period was 1.0 (range 0–11). A total of 76 laryngeal mask insertion attempts were recorded by 41 technicians and 30 paramedics. The median number of laryngeal mask insertions per paramedic/technician during the 12-month period was 0 (range 0–2). A survey of ongoing continuing professional development across all ambulance trusts demonstrated no provision for adequate training to compensate for the lack of clinical exposure to advanced airway skills. Conclusion: Paramedics use advanced airway skills infrequently. Continuing professional development programmes within ambulance trusts do not provide the necessary additional practice to maintain tracheal intubation skills at an acceptable level. Advanced airway management delivered by ambulance crews is likely to be inadequate with such infrequent exposure to the skill.

The provision of medical assistance by the ambulance service has evolved considerably since the introduction of advanced clinical skills in the 1970s. Many hospital-based procedures have been extended into the prehospital arena, with the questionable assumption that procedures performed in the hospital will be of benefit to patients if they are performed at the roadside. In particular, paramedic airway management now encompasses tracheal intubation, first introduced into UK practice in 1968, at a time when it was considered 888

to be the gold standard in airway management. As the safety and ease of use of supraglottic airways, in particular the laryngeal mask airway, have become established, further mirroring of hospital practice has also resulted in the introduction of these devices into prehospital care, for use by technicians and paramedics. Despite prehospital airway management being generally more challenging than that practised in the hospital, the training required for paramedics to be deemed competent in these advanced airway skills does not mirror that required for hospitalbased practitioners such as anaesthetists and emergency doctors. The Institute of Health & Care Development (IHCD) requirements mandate 25 tracheal intubations, and trainee paramedics are required to undertake a 2-week hospital-based attachment to achieve this. With fewer hospital patients requiring tracheal intubation and concerns over patient consent raised by the Association of Anaesthetists of Great Britain and Ireland,1 this number is becoming increasingly difficult to attain. This contrasts with doctors undergoing anaesthetic training who are not generally considered competent in unsupervised (although with more senior support immediately available) tracheal intubation until having undertaken at least a year of anaesthetic training during which time they would have typically inserted 200 tracheal tubes. Following initial training, skill fade of complex motor tasks is relatively rapid, particularly when initial training has been limited, and therefore, maintenance of skills following a relatively short initial training period will require regular exposure to the task. There are no published data documenting how much clinical airway management is undertaken by ambulance technicians and paramedics, which makes it difficult to assess whether skills are likely to be maintained through practicebased exposure following initial training. There are also no published data detailing the amount of refresher training undertaken by technicians and paramedics with respect to airway management that may be considered an acceptable substitute for infrequent clinical exposure to advanced airway skills. There is therefore a need to assess current paramedic airway practice in order to review whether initial training and maintenance of skills provide an acceptable level of competence with which to practice advanced airway skills. We therefore undertook a retrospective review of patient records to document current ambulance clinical practice with regard to use of advanced Emerg Med J 2009;26:888–891. doi:10.1136/emj.2008.064642

Prehospital care Table 1 Number of tracheal intubations per paramedic over the 12-month period. Number of tracheal intubations performed Number of tracheal intubations per paramedic over 12 months

0

1

2

3

4

5

6

7

8

9

10

11

128

76

28

22

7

1

2

1

0

1

2

1

airway skills and also a telephone survey of UK ambulance trust training schools to document the ongoing maintenance of advanced airway skills following initial training.

RESULTS Tracheal intubation Intubation success rate

MATERIALS AND METHODS

A total of 439 tracheal intubation attempts were recorded by all 269 paramedics. Of these, 368 were recorded as successful, giving an overall intubation success rate of 83.8%.

Following each clinical incident, ambulance crew complete a comprehensive patient report form (PRF), which records the clinical condition of the patient and any medical treatment or intervention administered. This form is subsequently scanned electronically and recorded on the trust database. Airway data recorded on forms from the Hampshire Division of South Central Ambulance Service (SCAS) during the period from 1 January 2007 to 31 December 2007 were analysed. Paramedics are taught to intubate patients 12 years or older and carry tracheal tubes of size 6.0 mm or greater to facilitate this. The smallest laryngeal mask airway that is carried is a size 2.5, which is suitable for use on patients of a comparable age. Inclusion criteria therefore reviewed PRFs corresponding to patients 12 years or older. Paramedic and technician identification codes were used to determine the number of airway procedures undertaken on an individual basis.

Intubations per paramedic per annum Of the 269 paramedics, 128 (47.6%) had undertaken no intubation and 204 (75.8%) had undertaken one or less intubation in the 12-month study period. The median number of intubations per paramedic during the 12-month period was 1.0 (range 0–11). Results are shown in table 1 and figure 1.

Attempts at intubation Of the 394 completed records documenting the number of tracheal intubation attempts for each patient (not recorded on 45 patient records), 81.2% (n = 320) were recorded as being successful on the first attempt (table 2).

Laryngeal mask insertion Ethics approval According to current National Health Service guidance, this retrospective review of patient records constitutes service evaluation and does not require ethics approval.

Over the same period, attempts at laryngeal mask (LM) insertion by 312 technicians and 269 paramedics were analysed.

Use of the LM as a first-line airway Of the 485 patients requiring an advanced airway (LM or tracheal tube), an LM was chosen as a first-line device in preference to a tracheal tube in 46 (9.5%) incidents.

LM usage A total of 76 LM insertion attempts were recorded by 41 technicians and 30 paramedics. The median number of LM insertions per paramedic/technician during the 12-month period was 0 (range 0–2). Overall, 87.8% technicians/paramedics had attempted no LM insertion in the 12-month period. Results are shown in table 3.

Use of LM as a failed intubation rescue airway In the 71 patients in whom tracheal intubation was unsuccessful, paramedics reverted to bag–valve mask in 57.7% (n = 41) and laryngeal mask in 42.3% (n = 30).

Cardiac arrest audit

Figure 1 Number of tracheal intubations per paramedic over the 12 month period

Airway management documented on anonymised PRFs for all cardiac arrest calls in the South Central region during July 2007 was also reviewed in detail. Cardiopulmonary resuscitation was indicated in 93 patients, all of whom were non-traumatic cardiac arrests.

Table 2 Number of tracheal intubation attempts Number of tracheal intubation attempts Number of patients

Emerg Med J 2009;26:888–891. doi:10.1136/emj.2008.064642

1 320

2 57

3 14

4 0

5 1

6 1

7 1

889

Prehospital care Table 3 Number of laryngeal mask insertions per technician/paramedic during the 12-month period. Number of LM insertions per technician/paramedic over 12 months (N = 581)

0

1

2

510

66

5

Doctors At two cardiac arrests, a British Association for Immediate Care (BASICS) doctor was present, and tracheal intubation was performed in both cases.

Survey of airway training in UK ambulance services

Technician-only crews Of the 13 patients attended by technician-only crews (trained in LM insertion, but not tracheal intubation), LM insertion was attempted on three patients, of which insertion failed in one patient. The remaining 10 patients were managed with a basic airway adjunct only (nasopharyngeal or oropharyngeal airway) combined with a bag–valve mask.

Paramedic crews Of the 78 patients attended by paramedic crews, intubation was not attempted or failed in 23 (30%) patients. In three of these 23 patients, a laryngeal mask was successfully used as a rescue airway, a bag–valve mask being used in the remainder. Of the remaining 55 patients, a laryngeal mask was used as the first choice of airway in three patients and a tracheal tube for 52 patients.

A survey of initial and ongoing training in advanced airway management across all ambulance trusts was undertaken. Training schools at ambulance trusts were contacted by telephone during May 2008. Anonymised results are shown in table 4. Ongoing continuing professional development (CPD) did not provide adequate training to compensate for the lack of clinical exposure to advanced airway skills.

DISCUSSION The SCAS comprises the counties of Hampshire, Berkshire, Oxfordshire and Buckinghamshire and serves a total population of 4 million in a mixture of large urban and smaller rural communities over an area of 4600 square miles. As with all UK ambulance trusts, clinical training previously followed the IHCD standards but is now in a transition period with IHCD courses being gradually phased out to be replaced by a 3-year foundation degree course. Clinical practice within SCAS follows

Table 4 Survey of airway training in UK ambulance services (as of 8 May 2008) LM use

Initial training

Technicians

Paramedics

Intubation

Trust A

Yes

Yes

Trust B

Yes

Yes

Trust C

Yes

Yes

Trust D

No

No

Trust E

Yes

Trust F

If qualified as technician for .3 years Yes

Trust G

No

Yes

Trust H

Yes

Yes

Trust I

Yes

Yes

Trust J

Yes

Trust K

Some (one of three regions trained) Yes

Trust L

No

Yes

Trust M

Yes

Yes

Trust N

Some

Yes

Trust O

No

Yes

Yes

Yes

Ongoing training Intubation

LM

20 Tracheal intubations 15 LM insertions on in theatre acceptable if manikin assessed as competent 25 Tracheal intubations 2 h With manikin in theatre

CPD

CPD

CPD

25 Although lesser numbers accepted 25 Tracheal intubations in theatre 25 Tracheal intubations in theatre

Competency-based manikin training N/A

CPD

12 LM insertions in the first year after training, then CPD CPD

CPD

N/A

20 LM insertions

CPD

CPD

25 Tracheal intubations in theatre, but less acceptable if judged as competent 25 Tracheal intubations in theatre 10 Tracheal intubations in theatre 25 Tracheal intubations in theatre 25 Intubations in theatre

Competency-based manikin training

Manikin assessment every second year

Manikin assessment every second year

25 LM insertions in theatre Competency-based manikin training Competency-based manikin training Five insertions on a manikin

Annual manikin assessment Annual manikin assessment CPD

Annual manikin assessment Annual manikin assessment CPD

CPD

CPD

Competency-based manikin training

CPD

CPD

Competency-based manikin training Competency-based manikin training

Annual manikin-based assessment Manikin-based assessment every second year CPD

Annual manikin-based assessment Manikin-based assessment every second year CPD

CPD, 1 day in theatre every third year if number of intubations deemed inadequate

CPD

13 Tracheal intubations accepted if assessed as competent 25 Tracheal intubations in theatre 5 Tracheal intubations in theatre

LM

25 Tracheal intubations Competency-based in theatre manikin training 20 Tracheal intubations Manikin training, in theatre followed by four LM insertions in theatre

CPD, continuous professional development; LM, laryngeal mask airway.

890

Emerg Med J 2009;26:888–891. doi:10.1136/emj.2008.064642

Prehospital care the Joint Royal Colleges Ambulance Liaison Committee guidelines in terms of skills that are taught and treatment recommendations. SCAS is therefore typical of most ambulance trusts in the UK with the training and clinical exposure of its ambulance staff.2 Initial training across most ambulance trusts is changing, with the IHCD requirement for 25 intubations generally being replaced with a more competency-based approach as trusts move towards a foundation degree course, often requiring less than the 25 tracheal tube insertions required in the past. Even for those being trained to IHCD requirements of 25 tracheal intubations, many trusts estimated that paramedics were being required to place fewer tracheal tubes than this, a reduction being driven by the increasingly limited use of tracheal intubation in general anaesthesia and patient consent issues raised by the Association of Anaesthetists of Great Britain and Ireland guidelines.1 One trust surveyed accepted as few as five tracheal tube insertions performed on patients undergoing general anaesthesia if the trainee paramedic was deemed as competent by a supervising clinician. As far as can be ascertained, the original IHCD requirement to insert 25 tracheal tubes was chosen because it was considered to be a reasonable number to provide an adequate level of competence, rather than a number based on a scientific evidence. The attainment of 25 tracheal intubations, however, does not guarantee competence because of the wide variation in the rate of skill acquisition between individuals.3 Although it is difficult to define the meaning of competent, there is little doubt that even 25 tracheal intubations are insufficient to enable paramedics to perform competently when managing these challenging airways. Competency in the anaesthetic room may not mean competency in the prehospital environment where airway management is generally more difficult. Three similar studies have found that novice anaesthetic trainees require 50– 60 attempts at tracheal intubation to achieve a 90% success rate.4–6 Based on these exponential learning curves, completion of 25 tracheal tube insertions would produce a success rate of approximately 70%. This is comparable with the data reported in this study. With most paramedics subsequently undertaking very few tracheal intubations after initial training, either on a manikin or in clinical practice, there is clearly little opportunity for further improvement in skills performance. Having completed initial training, paramedics’ regular exposure to tracheal intubation will be necessary to maintain tracheal intubation skills at an acceptable level. The shorter the initial training, the greater the amount of ongoing training necessary to maintain competence. The greater the number of patients intubated by a paramedic each year, the greater the intubation success rate (p,0.001, R = 0.32).7 8 In medical students given practical instruction in tracheal intubation, there was a significant decline in performance at 6 months, as shown by an increase in failure rate, increase in attempts at intubation, increased time to achieve intubation and increased dental trauma.9 The frequency with which advanced airway skills are practised by individual paramedics with respect to tracheal intubation was surprisingly infrequent. Approximately half of all paramedics had not intubated any patients in the preceding 12 months. Eighty-six per cent of paramedics had undertaken only two or less intubations in the same period. Clearly, this exposure to the skill is unlikely to maintain competence, particularly when relatively little additional manikin training is undertaken as part of annual refresher training.

Emerg Med J 2009;26:888–891. doi:10.1136/emj.2008.064642

It is also clear from these data that the laryngeal mask has yet to be accepted into clinical practice to the same extent as tracheal intubation. Not all trusts use laryngeal mask airways, and of those that do, initial training is generally manikin based. Ongoing maintenance of competence through clinical practice is unlikely to be achieved with such infrequent use, with 88% technicians and paramedics not using the airway over the 12month period. Even when tracheal intubation failed, the use of the laryngeal mask as a rescue airway was not standard practice, with most paramedics and technicians reverting to a bag–valve mask. Paramedics used the laryngeal mask as a first-line device when managing a cardiac arrest only in 3.8% (3/78) patients. There is now good evidence to suggest that initial current training in tracheal intubation is unlikely to equip paramedics with adequate skills to manage the challenging airways they are expected to deal with in the prehospital environment. Ongoing exposure to this skill is extremely limited and is not supplemented adequately by continuous professional development programmes within ambulance trusts. The practice of tracheal intubation following inadequate training may account for the findings of some studies showing that paramedic intubation may be associated with increased levels of morbidity and mortality.10–12 With evidence that tracheal intubation success rates are related to the amount of training given in the procedure, it is not surprising that a recent Cochrane review has acknowledged that the skill level of the operator may be key in determining efficacy of tracheal intubation.13 Standards for medical staff undertaking unsupervised hospital-based tracheal intubation far exceed those required of paramedics. With paramedics being expected to manage generally quite difficult airways, it is time that their training at least matches the standards expected for hospital practice to give them the necessary skills. Competing interests: CDD is a member of JRCALC and has chaired a recent review of paramedic airway practice. Provenance and peer review: Not commissioned; externally peer reviewed.

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