Hiroko Watase

Association Between Repeated Intubation Attempts and Adverse Events in Emergency Departments: An Analysis of a Multicenter Prospective Observational Study

STUDY OBJECTIVE Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events. METHODS We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation. RESULTS Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1). CONCLUSION In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.

Emergency airway management in Japan: Interim analysis of a multi-center prospective observational study ,

OBJECTIVES Emergency medicine is increasingly recognized as a medical specialty in Japan. However, comprehensive studies evaluating emergency airway management practice are lacking. We describe emergency department (ED) airway management using a large multi-center registry. METHODS We formed the Japanese Emergency Airway Network, a consortium of 10 academic and community medical centers in Japan, and prospectively collected data on ED intubations from April 2010 to February 2011. All patients undergoing emergency intubation were eligible for inclusion. Data were entered in real time by the intubator using a standardized data form. Variables included patients age, sex, weight, indication for intubation, methods of intubation, drugs, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We present descriptive data as proportions with 95% confidence intervals. RESULTS We recorded 1486 intubations (compliance rate 99%). Intubation was ultimately successful in 99.7%. The initial method of intubation varied substantially among the hospitals, including rapid sequence intubation (0-79%), sedation without paralysis (4-88%), paralysis without sedation (0-18%), and oral without medication (12-67%), in non-cardiac arrest encounters. Success rates in first and ≤3 attempts ranged from 40 to 83% and from 74 to 100%, respectively. The overall adverse event rate was 11%, without significant difference by the method used. CONCLUSIONS In this multi-center study characterizing ED airway management across Japan, we observed a high overall success rate but a high degree of variation among hospitals in the methods of intubation and success rates.

Quality of Care for Acute Asthma in Emergency Departments in Japan: A Multicenter Observational Study

BACKGROUND Little is known about the quality of acute asthma care in emergency departments (EDs) outside of North America. OBJECTIVE We evaluated concordance of acute asthma management in Japanese EDs with recommendations in the 2007 National Institutes of Health asthma guidelines and investigated whether guideline concordance was associated with risk of hospital admission. METHODS We conducted a multicenter chart review study in 23 EDs across Japan. We identified ED patients aged 18 to 54 years with acute asthma between 2009 and 2011. Concordance with evidence-based guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at patient and ED levels. These scores ranged from 0 to 100. RESULTS Among 1380 patients, the median age was 35 years and 11% were hospitalized. Overall guideline concordance score was suboptimal both at the patient level (mean ± SD, 72 ± 14) and ED level (mean ± SD, 72 ± 6). Specifically, asthma care at the patient level was suboptimal in several areas: inhaled anticholinergics in ED (2%), systemic corticosteroid in ED (56%) and at discharge (36%), and peak flow assessment (9%). A multivariable model that adjusted for severity at presentation and several ED characteristics showed that higher guideline concordance was associated with significantly lower risk of hospital admission (odds ratio, 0.70 per 10-unit increase in composite score; 95% CI, 0.62-0.79 per 10-unit increase in composite score). CONCLUSION The management of acute asthma in Japanese EDs is suboptimal. Greater concordance with guideline-recommended management might reduce unnecessary hospitalizations. Knowledge translation initiatives are warranted to increase adherence with best practice in acute asthma management.

Prospective validation of the modified LEMON criteria to predict difficult intubation in the ED

BACKGROUND Evidence to predict difficult intubation remains scarce in the emergency department (ED) setting. A previously defined clinical decision rule, the modified LEMON criteria, may provide a reliable and reproducible means of identifying difficult intubations. We aimed to prospectively evaluate the external validity of the modified LEMON criteria in the EDs. METHODS We conducted a 13-center prospective observational study, the second Japanese Emergency Airway Network study. We prospectively collected data on all patients undergoing intubations in the ED from February 2012 through September 2014. The primary outcomes were sensitivity, specificity, and predictive values of the modified LEMON criteria for predicting difficult intubation (≥2 attempts by emergency attending physicians or anesthesiologists). RESULTS The database recorded a total of 4034 encounters (capture rate, 96%) in the EDs. Of these, 3313 patients (84%) underwent the intubation attempt with a direct laryngoscope and 610 patients (16%) with a video laryngoscope. The proportion of difficult intubation was 5.4% (95% confidence interval [CI], 4.7%-6.2%) in the direct laryngoscope group and 7.4% (95% CI, 5.6%-9.7%) in the video laryngoscope group. The sensitivity was 85.7% (95% CI, 79.3%-90.4%) with direct laryngoscope and 94.9% (95% CI, 83.5%-98.6%) with video laryngoscope. The specificity was 47.6% (95% CI, 47.2%-47.9%) and 40.3% (95% CI, 39.4%-40.6%), respectively. The negative predictive value was 98.2% (95% CI, 97.5%-98.8%) and 99.0% (95% CI, 96.6%-99.7%), respectively. CONCLUSIONS In this multicenter prospective study, we found a high sensitivity and a negative predictive value of the modified LEMON criteria for predicting difficult intubation. The modified LEMON might assist ED providers in better identifying difficult intubations.

Repeated attempts at tracheal intubation by a single intubator associated with decreased success rates in emergency departments: an analysis of a multicentre prospective observational study.

Objective To determine whether the success rate of repeated attempts at tracheal intubation by a single intubator was lower than those by alternate intubators in the emergency department (ED). Methods An analysis of data from a multicentre prospective registry (Japanese Emergency Airway Network Registry) of 13 academic and community EDs in Japan between April 2010 and August 2012. We included all adult and paediatric patients who underwent repeated attempts at tracheal intubation in the ED. We compared the intubation success rates at the second and third attempts between attempts at intubation by a single intubator who performed the previous attempts, and the attempts by alternate intubators. Results We recorded 4094 patients (capture rate, 96%); 1289 patients with repeated attempts at tracheal intubation were eligible for this study. Among these, 871 patients (68%) had a second attempt at intubation by single intubators. At the second attempt, tracheal intubation by a single intubator was associated with a decreased success rate (adjusted odds ratio or AOR, 0.50; 95% CI 0.36 to 0.71), compared with alternate intubators. At the third attempt, intubation by a single intubator was also associated with a decreased success rate (58% vs 70%; unadjusted OR, 0.58; 95% CI 0.38 to 0.89). However, after adjustment for potential confounders, the association lost statistical significance (AOR, 0.89; 95% CI 0.52 to 1.56). Conclusions In this large multicentre study of ED patients undergoing tracheal intubation, second attempts at intubation by a single intubator, compared with those by alternate intubators, were independently associated with a decreased success rate.

Emergency airway management by resident physicians in Japan: an analysis of multicentre prospective observational study

To examine the success rates of emergency department airway management by resident physicians in Japan.

Techniques and outcomes of emergency airway management in Japan: An analysis of two multicentre prospective observational studies, 2010–2016

OBJECTIVES Continuous surveillance of emergency airway management practice is imperative in improving quality of care and patient safety. We aimed to investigate the changes in the practice of emergency airway management and the related outcomes in the emergency departments (EDs) in Japan. METHODS We conducted an analysis of the data from two prospective, observational, multicentre registries of emergency airway management-the Japanese Emergency Airway Network (JEAN)-1 and -2 Registries from April 2010 through May 2016. RESULTS We recorded 10,927 ED intubations (capture rate, 96%); 10,875 paediatric and adult patients were eligible for our analysis. The rate of rapid sequence intubation (RSI) use as the initial intubation method significantly increased from 28% in 2010 to 53% in 2016 (Ptrend=0.03). Likewise, the rate of video laryngoscope (VL) use as the first intubation device increased significantly from 2% in 2010 to 40% in 2016 (Ptrend<0.001), with a significant decrease in the rate of direct laryngoscope use from 97% in 2010 to 58% in 2016 (Ptrend<0.001). Concurrent with these changes, the overall first-attempt success rate also increased from 68% in 2010 to 74% in 2016 (Ptrend=0.02). By contrast, the rate of adverse events did not change significantly over time (Ptrend=0.06). CONCLUSION By using data from two large, multicentre, prospective registries, we characterised the current emergency airway management practice, and identified their changes in Japan. The data demonstrated significant increases in the rate of RSI and VL use on the first attempt and the first-attempt success rate over the 6-year study period.

Multicentre observational study of adults with asthma exacerbations: who are the frequent users of the emergency department in Japan?

Objectives Emergency department (ED) visits for asthma exacerbation reflect a failure of longitudinal asthma management. However, little is known about the characteristics of patients with frequent ED visits (≥2 visits in a 1-year period). We aimed to characterise the adult patients who frequently presented to the ED for asthma exacerbation in Japan. Design A multicentre chart review study of 23 EDs across Japan. Participants Adults aged 18–54 years who presented to the ED with asthma exacerbation from 2009 to 2011. Outcome measures Frequency of ED visits for asthma exacerbation in a 1-year period, including the index ED visit. Results Of the 1002 eligible patients, 218 (22%) had frequent ED visits, accounting for 48% of total ED visits for asthma exacerbation in the 1-year period. Specifically, 12% had 2 ED visits and 10% had ≥3 visits. In these patients, guideline-recommended chronic management was suboptimal. For example, among patients with ≥3 ED visits, only 63% were treated with inhaled corticosteroids and 49% were current smokers. In a multinomial logistic regression model, markers of chronic asthma severity (history of hospitalisation for asthma and use of inhaled corticosteroids) were significantly associated with a higher frequency of ED visits (both p<0.05). Conclusions This multicentre study in Japan demonstrated that many patients are frequent ED users for asthma exacerbation. We also found that their asthma control management is suboptimal, most likely contributing to worse chronic severity and more frequent ED visits. Further dissemination and adoption of evidence-based guidelines are required to reduce asthma morbidity in this high-risk population.

Infectious disease frequency among evacuees at shelters after the great eastern Japan earthquake and tsunami: a retrospective study.

OBJECTIVE After the Great Eastern Japan Earthquake and tsunami, the World Health Organization cautioned that evacuees at shelters would be at increased risk of infectious disease transmission; however, the frequency that occurred in this population was not known. METHODS We reviewed medical charts of evacuees who visited medical clinics at 6 shelters from March 19, to April 8, 2011. Excluded were patients who did not reside within the shelters or whose medical records lacked a name or date. We investigated the frequency of and cumulative incidences of acute respiratory infection [ARI], acute gastroenteritis, acute jaundice syndrome, scabies, measles, pertussis, and tetanus. RESULTS Of 1364 patients who visited 6 shelter clinics, 1167 patients (86.1%) were eligible for the study. The median total number of evacuees was 2545 (interquartile range [IQR], 2277-3009). ARI was the most common infectious disease; the median number of patients with ARI was 168.8 per week per 1000 evacuees (IQR, 64.5-186.1). Acute gastroenteritis was the second most common; the median number of patients was 23.7 per week per 1000 evacuees (IQR, 5.1-24.3). No other infectious diseases were observed. The median cumulative incidence of ARI per 1000 evacuees in each shelter was 13.1 person-days (IQR, 8.5-18.8). The median cumulative incidence of gastroenteritis was 1.6 person-days (IQR, 0.3-3.4). CONCLUSION After the Great Eastern Japan Earthquake and tsunami, outbreaks of ARI and acute gastroenteritis occurred in evacuation shelters.

3D true-phase polarity recovery with independent phase estimation using three-tier stacks based region growing (3D-TRIPS)

ObjectivesA postprocessing technique termed 3D true-phase polarity recovery with independent phase estimation using three-tier stacks based region growing (3D-TRIPS) was developed, which directly reconstructs phase-sensitive inversion-recovery images without acquisition of phase-reference images. The utility of this technique is demonstrated in myocardial late gadolinium enhancement (LGE) imaging.Materials and methodsA data structure with three tiers of stacks was used for 3D-TRIPS to directly achieve reliable region growing for successful background-phase estimation. Fifteen patients undergoing postgadolinium 3D phase-sensitive inversion recovery (PSIR) cardiac LGE magnetic resonance imaging (MRI) were recruited, and 3D-TRIPS LGE reconstructions were compared with standard PSIR. Objective voxel-by-voxel comparison was performed. Additionally, blinded review by two radiologists compared scar visibility, clinical acceptability, voxel polarity error, or groups and blurring.Results3D-TRIPS efficiently reconstructed postcontrast phase-sensitive myocardial LGE images. Objective analysis showed an average 95% voxel-by-voxel agreement between 3D-TRIPS and PSIR images. Blinded radiologist review demonstrated similar image quality between 3D-TRIPS and PSIR reconstruction.Conclusion3D-TRIPS provided similar image quality to PSIR for phase-sensitive myocardial LGE MRI reconstruction. 3D-TRIPS does not require acquisition of a reference image and can therefore be used to accelerate phase-sensitive LGE imaging.