单一医疗系统内不同急诊科的插管实践与结局

文献信息

中文摘要

引言： 气管内插管（ETI）是急诊科（ED）常实施的一种救命性操作。既往研究表明，不同急诊科在ETI经验、实践和结局方面存在显著差异。医疗系统通常包含多种急诊环境，从大型学术医院到社区医院和独立急诊科。然而，关于单一医疗系统内ETI经验和结局如何变化，目前知之甚少。本研究旨在比较同一医疗系统内代表不同实践环境的三个急诊科的首次尝试成功率。
方法： 这项回顾性观察研究使用2021年11月至2025年1月期间1,659例ETI事件的机构数据，比较代表不同环境谱系的三个急诊科的ETI相关结局：学术性一级创伤中心（A）；社区教学医院（B）；以及非教学社区站点（C）。主要结局指标为首次尝试成功率。我们还评估了气道不良结局以及ETI相关的患者和操作特征。采用卡方检验评估ETI相关结局与医院站点之间的关联。
结果： 三个站点的年急诊量分别约为82,000例（A）、64,000例（B）和49,000例（C），每1,000例患者中相应的ETI例数分别为5例、2例和0.4例。社区教学医院的首次尝试成功率最高，为90.2%（B：331/367；95% CI，87.2-93.2），其次是学术中心，为84.6%（A：1038/1227；95% CI，82.6-86.6），然后是非教学社区站点，为78.5%（C：51/65；95% CI，68.5-88.5）（P = .01）。气道不良结局发生于10.5%的ETI中，且各站点间无显著差异（A：139/1,227 [11.3%]；B：29/367 [7.9%]；C：6/65 [9.2%]，P = .16）。三个站点最常见的指征均为气道保护，其次是精神状态改变和心肺骤停。在A医院，大多数ETI由受训人员实施（1,096/1,227；89.3%），而在B（295/367；80.4%）和C（64/65；98.5%）则由主治医师主导。
结论： 我们发现三个急诊科站点之间的首次尝试成功率存在显著差异，尽管总体成功率和气道不良结局相当。这些发现提示，首次尝试成功率可能受到患者差异、喉镜操作者的角色和培训水平，以及患者量和病情严重程度等站点固有差异等因素的影响。

英文摘要

INTRODUCTION: Endotracheal intubation (ETI) is a life-saving procedure commonly performed in emergency departments (ED). Prior research has demonstrated significant variability in ETI experience, practices, and outcomes across EDs. Health systems often include a mix of ED environments, from large academic hospitals to community-based and freestanding EDs. However, little is known about how ETI experiences and outcomes vary within a single health system. Our objective in this study was to compare first-attempt success across three EDs representing different practice environments but within one health system.
METHODS: This retrospective observational study used institutional data from 1,659 ETI events between November 2021-January 2025 to compare ETI-related outcomes across three EDs representing a spectrum of settings: an academic Level I trauma center (A); a community teaching hospital (B); and a nonteaching community site (C). Our primary outcome measure was first-attempt success. We also assessed adverse airway outcomes and ETI-related patient and procedural characteristics. Chi-square tests evaluated the association of ETI-related outcomes and hospital sites.
RESULTS: Annual ED volumes were approximately 82,000 (A), 64,000 (B), and 49,000 (C), with respective ETI encounters per 1,000 patients of 5, 2, and 0.4. The community teaching hospital had the highest first-attempt success rate of 90.2% (B: 331/367; 95% CI, 87.2-93.2), followed by the academic center with 84.6% (A: 1038/1227, 95% CI, 82.6-86.6), and then by the nonteaching community site with 78.5% (C: 51/65; 95% CI, 68.5-88.5) (P = .01). Adverse airway outcomes occurred in 10.5% of ETIs and did not vary significantly between sites (A: 139/1,227 [11.3%]; B: 29/367 [7.9%]; C: 6/65 [9.2%], P = .16). The most common indication was airway protection, followed by altered mental status and cardiopulmonary arrest for all three sites. Trainees performed the majority of ETIs at hospital A (1,096/1,227; 89.3%), while attending physicians predominated at B (295/367; 80.4%) and C (64/65; 98.5%).
CONCLUSION: We found significant variation in first-attempt success between the three ED sites, although overall success and adverse airway outcomes were comparable. These findings suggest that first-attempt success may be impacted by factors such as patient differences, role and training level of laryngoscopists, and inherent site-level differences such as patient volume and acuity.