Should non-anaesthetists perform pre-hospital rapid sequence induction? an observational study

Abstract

Introduction: The use of rapid sequence induction and tracheal intubation (RSI) in the pre-hospital environment is controversial. Currently, it is felt that competence to perform RSI should be defined by skills in anaesthesia not by the primary speciality of a practitioner. This aim of the study was to evaluate the tracheal intubation success rate of doctors drawn from different clinical specialities performing RSI in the pre-hospital environment.

Method: Retrospective review of all RSI performed by doctors operating on the Warwickshire and Northamptonshire Air Ambulance over a 5-year period. Tracheal intubation failure rates were calculated and analysed for proportional differences between groups by χ(2) and, where appropriate, Fisher's exact test.

Results: 4362 active missions were flown. RSI was performed in 200 cases (4.6%, 3.1/month). Successful intubation occurred in 194 cases, giving a failure rate of 3% (6 cases, 95% CI 0.6 to 5.3%). While no difference in failure rate was observed between emergency department (ED) staff and anaesthetists (2.73% (3/110, 95% CI 0 to 5.7%) vs 0% (0/55, 95% CI 0 to 0%); p=0.55), a significant difference was found when non-ED, non-anaesthetic staff (GP and surgical) were compared to anaesthetists (10.34% (3/29, 95% CI 0 to 21.4%) vs 0%; p=0.04). There was no significant difference associated with seniority of practitioner (p=0.65).

Conclusions: Non-anaesthetic practitioners have a higher tracheal intubation failure rate during pre-hospital RSI. This likely reflects a lack of training opportunities and infrequency of clinical experience. Strategies to improve pre-hospital airway management are required.