Risk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approach

Abstract

Introduction: Endotracheal intubation (ETI) has been considered an essential part of pre-hospital advanced life support. Pre-hospital ETI, however, is a complex intervention also for airway specialist like anaesthesiologists working as pre-hospital emergency physicians. We therefore wanted to investigate the quality of pre-hospital airway management by anaesthesiologists in severely traumatised patients and identify possible areas for improvement.

Method: We performed a risk assessment according to the predictive Bayesian approach, in a typical anaesthesiologist-manned Norwegian helicopter emergency medical service (HEMS). The main focus of the risk assessment was the event where a patient arrives in the emergency department without ETI despite a pre-hospital indication for it.

Results: In the risk assessment, we assigned a high probability (29%) for the event assessed, that a patient arrives without ETI despite a pre-hospital indication. However, several uncertainty factors in the risk assessment were identified related to data quality, indications for use of ETI, patient outcome and need for special training of ETI providers.

Conclusion: Our risk assessment indicated a high probability for trauma patients with an indication for pre-hospital ETI not receiving it in the studied HEMS. The uncertainty factors identified in the assessment should be further investigated to better understand the problem assessed and consequences for the patients. Better quality of pre-hospital airway management data could contribute to a reduction of these uncertainties.

Figure 1

Fault tree visualising the process leading up to the top event.

Figure 2

Influence diagram illustrating the impact of the risk influencing factors on the basic events of the fault tree. The impact is shown as normalized weights, meaning that the sum of impacts on each basic event is 1.0 and the impact of each risk influencing factor represents a fraction of this.

Figure 3

Event tree visualising the possible outcomes of the event being assessed.

Figure 4

Risk matrix with possible consequences of the event that a patient arrives in the emergency department without endotracheal intubation, when there was an indication for endotracheal intubation pre-hospital. The figures indicate the assigned probabilities for the outcomes.