A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.

OBJECTIVES: To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies.

METHODS: Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an "endotracheal tube balloon below the cords" on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated.

RESULTS: Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).

CONCLUSIONS: Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.