January 2020

Clinical Question:

How many tubes do we need to stay current?

Title of Paper:

Skill Proficiency is Predicted by Intubation Frequency of Emergency Medicine Attending Physicians

Journal and Year:

Western Journal of Emergency Medicine. July 2019.

Lead Author:

Brian Gillett

Background:

* Every country and training program has different requirements for airway training and the actual definition of airway competence is one that will probably be debated on twitter until the end of time

* Once you are proficient at emergency RSI, however, how long does that last? What is required to keep yourself current?

* As John Hinds said in our podcast with him in 2015, you need to be Competent, confident, _current_

Study Design:

* Cross-sectional study to determine factors related to intubation frequency that correlated with assessed skill of ETI via DL on an airway simulator.

* Subsequent analysis of factors with good correlation to identify intubation frequencies that could predict assessment scores below a defined proficiency level.

Doctors Studied:

* Full time employed attending physicians, board certified or board eligible in EM, PEM or both.

What did the do?

* Intubation assessment – each doc was individually assessed intubating by DL on a mannequin (see pic)

* Assessed them for successful completion of 11 checklist items, scored 0-10:

* Assembly of equipment:

* Suction

* Correct sized ETT and blade

* Back up tube and blade

* Rescue device

* Stylet

* Confirmation device

* Discrete actions:

* Evaluated airway anatomy and mobility

* Positions appropriately

* Articulates RSI meds

* Does not rock laryngoscope handle backwards on insertion

* Inserts tube to correct depth

* Also used a psychomotor adeptness rating (0-10) for coordination, grace, dexterity and timing

* Developed a proficiency cut-off score based on median scores achieved by docs deemed ‘not clearly proficient’ or ‘clearly not proficient’

Outcomes:

* Primary: strength of correlation between DL ETI assessment scores and:

* Time since last intubation

* Time since last supervising intubation

* Mean number of intubations performed annually

* Mean number of intubations supervised annually

* Secondary: Identification of intubation frequencies that predict physician score below the established proficiency score on the airway assessment.

Summary of Results:

* 32 docs (24 EM, 8 PEM)

* Mean years practice (since residency) 10.3 years

* General EM:

* Performed 4.2 intubations / year

* Supervised 5.3 intubations / year

* PEM

* Performed 0.2 intubations / year

* Supervised 0.3 intubations / year

* Boarderline performers

* n = 14 (10 EM 4 PEM)

* Median assessment score 79%

* Scores correlated well with average intubations performed and supervised per year (r 0.6 both)

* Did not correlate (weakly -ve) as well with time since last supervising or performing or years experience (r -0.5, -0.3, -0.4)

* ROC analysis – Docs would score ≥ cut off proficiency if:

* Performed average of ≥ 3 intubations annually (Sn 90%, Sp 64%, AUC 0.87)

* Supervised average ≥ 5 intubations annually (Sn 90%, Sp 59%, AUC 0.81)

Authors Conclusion:

Performing at least three or supervising at least five ETIs per year correlated with proficient performance on a skills assessment in our cohort.  Our methodology is easily replicable and can be extrapolated across a wide rage of procedures in future studies.  Since simulation training has become widely available, we advocate for this modality as a platform for active maintenance and advancement of procedural skills.

Clinical Bottom Line:

Ok its based on a new method of assessment on a mannequin, but at least it gives us an objective measure.  Like with any of our skills, the responsibility to keep competent, confident and current lies with ourselves, and we’ll all have different requirements.  That being said – this study should at least give us a bench mark to work towards – if you are performing < 3 or supervising < 5 intubations per year on average, then maybe you should consider a course or a couple of days in anaesthetics to bring your currency up.
### Other #FOAMed Resources / References:

RCEMLearning Podcast 2015 with John Hinds

Authors:

Mark interviewing Dr Govind Oliver at ASC 2019 on his rod little presentation “Computer beat doctor? Estimating the probability of ACS for individual patients

Clinical Question:

Does early initiation of antibiotics improve mortality in sepsis?

Title of Paper:

ED Door-to-Antibiotic Time and Long-term Mortality in Sepsis

https://www.ncbi.nlm.nih.gov/pubmed/30779916

https://www.ncbi.nlm.nih.gov/pubmed/30779916

Journal and Year:

Chest. 2019.

Lead Author:

Peltan

Background:

* We are forever debating, investigating, disagreeing, guidelining etc for what is sepsis? How much fluid should we give? Which fluid? Which antibiotics? When?

* International guidelines recommend patients with sepsis get antibiotics within 1-h of ED arrival (Americans) – or within 1-hr of identification of sepsis (actual guidelines)

* Expediting antibiotic administration can come with its own problems – diagnostic / treatment delays, complications of abx, and long term sequelae such as resistance

Study Design:

* Retrospective cohort of adult patients presenting to two community and two tertiary hospitals in Utah

Patients Studied:

* Adults exhibiting ‘clinical sepsis’ in the ED

* Third international consensus (Sepsis-3) standard (suspected infection and qSOFA ≥ 2)

* Excluded: Trauma and patients who died in ED

Exposure:

* Door-to-antibiotic time

Outcomes:

* Primary: 1-year mortality

* Secondary: hospital, 30-day, 90-day mortality

* Secondary analysis:

* ≤ 1h vs each 1-h door-to-antibiotic interval

* > 1h vs ≤ 1h

* > 3h vs ≤ 3h

Summary of Results:

* 10,811 patients included

* 8% died within 30 days

* 19% died within a year

* Median d-a time 166 minutes

* ≤ 3h patients were older, sicker (acutely and chronically) with more co-morbidities, more organ failure, more physiological  derangement

* Crude 30-d mortality higher in d-a time ≤ 3h (_sicker patients_)

* 9% vs 7%

* No difference at 1 year mortality

* After adjustment: (disease severity and other confounding factors)

* Each 1-h increase in d-a time was associated with 10% [5-14%] increase in odds of 1-year mortality

* 1.1% increase in expected mortality for each additional hour of d-a time

* Similar for hospital, 30 day and 90 day mortality

* > 3h vs ≤3 h associated with increased aOR mortality 1-year (aOR 1.27 [1.12-1.43] p <0.001) * No difference in the >1h vs ≤1h groups (aOR 1.26 [0.98-1.62])

* Each extra hour relative to ≤ 1h showed fairly linear increase in 1-year, 30-day and 90-day mortalities

* The 1.1% per hour increase in risk adjusted absolute mortality suggests that decreasing average d-a time to 1.5h could prevent one death per 61 ED patients with sepsis (NNT 61 to prevent death)

Authors Conclusion:

Increasing door-to-antibiotic time for ED patients with clinical sepsis was associated with a linear, hour-by-hour increase in 1-year mortality and possibly with persistent increases in mortality among survivors of the initial illness. Innovative trail designs are needed to test method to accelerate appropriate antibiotic initiation and determine whether these interventions improve patient-centred outcomes.

Clinical Bottom Line:

This is observational data only and association does not = causation.  But it adds strength to early appropriate assessment and commencement of timely AND appropriate antibiotics in patients with sepsis.
### Other #FOAMed Resources / References:

[REBELEM] Time to Abx in Sepsis

Chris had the chance to catch up with Gordon at the annual scientific conference in Newcastle and they talked over head injuries in patients taking DOACS.

Some additional reading here

The AHEAD paper is here
Here’s the systematic review he talks to us about