Emergency Medicine

Observational videos can identify ways to improve emergency endotracheal intubation

Analysis of 50 video recordings of real patient resuscitation at 1 trauma center revealed many breaks in protocol that could not have been discovered through traditional quality improvement (QI) methods such as medical record review and postprocedure interviews.

The videos helped identify accident precursors, unsafe acts, and systems failures. Video-identified accident precursors included lengthy preoxygenation with a facemask before endotracheal intubation, which delayed recognition that the patient lacked sufficient oxygen after tube misplacement. Also, the ventilation circuit used before and after emergency intubation had no carbon dioxide analyzer connections. These connections are needed to assess adequacy of bag-mask-valve ventilation and to confirm tracheal, not esophageal intubation.

The videos also revealed unsafe acts. For example, they showed that two anesthesia care providers did not carry a stethoscope to listen to the patient's chest (standard operating procedure), carbon dioxide analysis (standard criterion to detect lung ventilation) was delayed for 5 minutes after intubation, and no reoxygenation was established before reattempted intubation.

Colin F. Mackenzie, M.B.Ch.B., F.R.C.A., of the University of Maryland School of Medicine, and colleagues found 28 performance deficiencies that included communication failures, lack of timely vital signs monitoring, and lack of tracheal intubation equipment checks. When procedures were revised to include clinical examination by a laryngoscopist, communication of clinical findings, and carbon dioxide testing immediately after intubation, it mitigated task and communication deficiencies.

These differences were observed on video records from 1995 and 2005 compared with 1993 and 1994. Limitations in using video for QI include lengthy video review processes, poor audio quality, and inability to analyze events outside the field of view, as well as significant medicolegal and confidentiality issues.

The study was supported in part by the Agency for Healthcare Research and Quality (HS11562).

More details are in "Video as a tool for improving tracheal intubation tasks for emergency medical and trauma care," by Dr. Mackenzie, Yan Xiao, Ph.D., Fu-Ming Hu, M.S., C.N.E., and others, in the October 2007 Annals of Emergency Medicine 50(4), pp. 436-442.

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