The guideline emphasized step-wise escalation in airway management from BVM to EGA to ETI, only if the less invasive method was not effective .HFD is a two-tiered 9-1-1 EMS system with Basic Life Support and Advanced Life Support units. HFD serves a geographic area totaling 2.3 million persons and 667 square miles in the greater Houston region. The agency receives 300,000 EMS calls annually. No other EMS agencies provide emergency 9-1-1 response within Houston city limits. HFD has 3500 prehospital providers, all of whom are trained as firefighters and have at least BLS emergency medical technician training. HFD also has 700 paramedics providing ALS care. Dispatch of the initial unit is determined based on the 9-1-1 call type and severity. The local EMS protocol for management of respiratory failure in pediatric patients changed to include the use of an EGA for pediatric patients – the i-gel – in addition to algorithmic progression from one device to a more advanced device. Prior to the protocol change no EGA device was available for pediatric airway management due to the size restrictions of the then-used King LT-D airway . Prior to the protocol change pediatric patients with respiratory failure or cardiac arrest were managed first with BVM followed by intubation. Both ALS and BLS providers were equipped with the i-gel EGA post-protocol change for both adults and pediatric patients. The King LT-D was not available post-protocol change. The airway management protocol directed members to use BVM first and then advance to an EGA for all patients requiring transport and continued assisted ventilation. If the EGA provided inadequate oxygenation or ventilation it could be removed,vertical grow racks for sale with intubation attempted by a paramedic. The new protocol inclusive of EGAs was implemented in conjunction with an in-person lecture and skills training described in a prior publication.
All study patients received ALS care.We retrospectively reviewed electronic patient data to establish the baseline characteristics, incidence of airway procedures, and outcomes for patients meeting this study’s inclusion criteria . Prospective patients were electronically identified on a weekly basis via the patient care record and cardiac arrest quality-assurance databases. Records were reviewed by trained abstractors who were aware of the study design and outcomes in question. Hospital and outcome data were abstracted from the EMS agency’s cardiac arrest database and hospital inpatient medical records.Our primary outcome was a difference in the frequency of prehospital attempted intubations between the pre- and post-intervention groups. We estimated a 20% reduction in intubation rate from implementation of the new protocol with a sample size of 266 . For skewed continuous data we used non-parametric testing . Incomplete data or negative timed operational metrics were coded as missing. We analyzed categorical variables using the Pearson chi-square test or Fisher’s exact test. A p-value less than 0.05 was considered statistically significant. Categorical variables were reported using frequencies and percentages, continuous variables were reported using median and interquartile ranges. We conducted all analyses using the Statistical Package for the Social Sciences , version 24 .In this observational study, we found that the establishment of an airway management algorithm paired with an EGA suitable for all ages of pediatric patients decreased the rate of ETI in an urban EMS system. No differences in survival to hospital admission or discharge were observed in all patients with cardiac arrest or respiratory failure. For cardiac arrest patients specifically, we observed no difference in rates of ROSC. These observations suggest that deployment of a pediatric EGA can successfully decrease the need for prehospital intubation. Although prior research suggests no improvement in neurologic outcome with ETI,the skill is taught as part of the EMT-Paramedic National Standard Curriculum and still widely practiced in EMS agencies across the U.S.
As many EMS agencies progress toward widespread EGA deployment given evidence against significant benefits from intubation during initial cardiac arrest care, intubation skill retention remains largely unknown.For pediatric patients especially, the effects of implementing an EGA-first strategy decreases a paramedic’s exposure to the already rare intubation. Prior research has demonstrated a low number of clinical opportunities for paramedics to maintain procedural competency with intubation,let alone the exceedingly rare pediatric intubation. In our cohort, we observed a decline in the success rate for pediatric intubations when attempted after introducing an EGA. The effects of implementing the EGA in this system, while continuing to allow ETI, resulted in a further dilution of procedural experience. The potential difficulty with maintaining paramedic intubation skills for pediatric and adult patients, is well documented by prior studies,and may be augmented in systems such as this where ETI exists concurrently with EGA prioritization. The potential training solutions and their effectiveness have not been described. High-performance EMS agencies with intensive training, continuing education, and quality assurance report intubation success rates as great as 97% but with low first-pass success.Systems with infrequent airway management training and skill maintenance when coupled with the addition and widespread use of EGAs may experience declines in success, as those observed in our system. However, in the intubations that occurred post-protocol change, 96.4% occurred due to protocol non-adherence. Despite our reported 95% success rate with EGA placement, which is consistent with previous publications,many patients during the study period still underwent ETI attempts. Of the 36.4% with ETI attempted prior to an EGA attempt only, 85% experienced a success. Similarly, only 54.4% were successful when attempted after an already successful EGA. Although prior commentary has suggested that EGAs, specifically the i-gel, perform well in the prehospital environment, success rates may be lower than previously demonstrated in hospital-based studies.
In non-paralyzed adults, for example, ventilation with the adult size 4 i-gel may exceed the 24 millimeters of mercury laryngeal seal, causing significant air leak.For children, the degree of leak if the device is sized incorrectly is unknown. For our cohort, the rationales behind the protocol deviations were not consistently documented. It is possible that many of the ETIs after EGA placement were in fact warranted but appeared as protocol violation due to inadequate documentation of EGA failure. Providers’ perception of inadequate ventilation or incorrect device sizing may have contributed to the intubation attempts occurring after initial EGA placement. Our study was not powered to detect a prehospital ROSC or survival benefit in cardiac arrest patients.In this small cohort we did not observe any measurable effects on cardiac arrest care, although metrics such as compression fraction, CPR rate, and exact timing of EGA or ETI were not available. Also, given our small sample size and low frequency of shockable rhythms in the pediatric population,further research is required to address the initial airway management device by rhythm and likelihood of a primary respiratory arrest. Opioid use disorder is associated with excess mortality, morbidities,rolling hydro tables and other adverse health and social conditions . OUD is common among individuals with chronic pain conditions, and chronic pain is common among individuals with OUD . The relationship between chronic pain and OUD and the time course of the two is complex; chronic pain may precede prescription opioid use and addiction or may develop after OUD, either as an expected health condition or as a consequence of OUD. Substance use is a risk factor for car accidents and violent crime, which often lead to injuries that are associated with chronic pain . On the other hand, individuals with chronic pain often take opioids to relieve pain, and opioid therapy is the most commonly prescribed treatment for severe chronic pain, even though long-term opioid therapy remains controversial for chronic non-cancer pain due to its questionable efficacy and association with opioid misuse and use disorders in some individuals. Complicating the issue is that other physical health and mental health problems often cooccur with OUD and chronic pain. For example, OUD patients are up to 11 times more likely than the general population to have a mood disorder, and they have up to 8 times greater rates of anxiety disorders . Individuals with depression, schizophrenia, and bipolar disorder are significantly more likely to have chronic pain relative to those without these psychiatric conditions . The overlapping risk factors and causes of these diseases and chronic conditions are difficult to disentangle. Optimizing treatment for patients with these complex medical conditions has become a nationally recognized target for healthcare improvement . There is limited knowledge about chronic pain conditions, other co-morbid health and mental health conditions, and healthcare utilization among OUD patients treated in general medical or healthcare systems.
Most knowledge of OUD is based on self-reports from individuals treated in publicly funded addiction specialty programs. The availability of electronic health records provides the opportunity to efficiently examine the health status and service use among large and diverse samples in general healthcare systems . This is particularly important because the non-medical use of prescription opioids is now recognized to be a national epidemic in the United States, making prescription opioid misuse and overdose deaths a critical public health problem . EHR systems represent a new but underutilized research resource that allows OUD and related physical and mental health conditions to be studied in general healthcare systems. The goal of this study was to examine chronic pain among patients with OUD, as well as to examine other substance use disorders, health, mental health, and treatment for health and mental health among patients in medical settings using EHRs. We divided our sample into four clinically relevant groups related to the intersection and time course of OUD and chronic pain diagnoses: those with no chronic pain , those with chronic pain after OUD , those having both at the same time or clinic visit , and those with chronic pain before OUD . By comparing the four groups, we can examine the association between presence of chronic pain conditions and other psychiatric and medical conditions, as well as the prevalence of these conditions in association with the order of first pain diagnosis versus first OUD diagnosis. Based on previous research, we hypothesized that chronic pain conditions in OUD patients would be associated with greater prevalence of mental health disorders and physical health conditions than that among OUD patients without chronic pain diagnoses; the OUD-only group however, would have greater prevalence of other substance use disorders than OUD patients with chronic pain conditions. Further, we hypothesized that people in the OUD First group would have higher rates of other substance use disorders, mental health problems, and physical health problems than individuals in the Pain First group but similar prevalence rates of other substance use disorders as those in the Same Time group. Findings are important to extend knowledge of relative differences in psychiatric and medical comorbidities among patients with OUD and chronic pain in order to inform clinical practice related to screening patients with these commonly related conditions and targeting treatment interventions for them. In terms of other substance use disorders, the four groups differed significantly in all substances examined except for sedative/hypnotic/anxiolytic use disorder . The OUD First group had the highest prevalence rates of alcohol, cocaine, and other drug use . This group also had the highest rates of alcohol- or drug-induced disorders. The No Pain group had the highest rate of amphetamine use and the lowest rate of tobacco use. The highest rate of sedative/hypnotic/anxiolytic use but lowest rates of alcohol, cannabis, amphetamine, cocaine, and hallucinogen use disorders were found in the Pain First group and the Same Time group. Approximately 70% of the sample had a co-morbid mental health disorder, and the four groups also significantly differed in prevalence of any mental disorder or each specific type of mental disorder with only one exception, psychotic disorder. In general, the three groups with chronic pain conditions had higher rates of mental disorders in comparison to the No Pain group. Even among the No Pain group, more than 50% had co-morbid psychiatric diagnoses. Approximately half of each of the groups with chronic pain suffered from a depressive disorder, 40% had an anxiety disorder, and 40% had mental disorders other than psychosis, depression, anxiety, or bipolar disorders, with the highest rates consistently among the Pain First group.This study adds to a rapidly growing knowledge base concerning the intersection of chronic pain and opioid use disorder occurring in a large healthcare organization.