Impact of Post-Intubation Interventions on Mortality in Patients Boarding in the Emergency Department

Introduction: Emergency physicians frequently perform endotracheal intubation and mechanical ventilation. The impact of instituting early post-intubation interventions on patients boarding in the emergency department (ED) is not well studied. We sought to determine the impact of postintubation interventions (arterial blood gas sampling, obtaining a chest x-ray (CXR), gastric decompression, early sedation, appropriate initial tidal volume, and quantitative capnography) on outcomes of mortality, ventilator-associated pneumonia (VAP), ventilator days, and intensive care unit (ICU) length-of-stay (LOS). Methods: This was an observational, retrospective study of patients intubated in the ED at a large tertiary-care teaching hospital and included patients in the ED for greater than two hours postintubation. We excluded them if they had incomplete data, were designated "do not resuscitate," were managed primarily by the trauma team, or had surgery within six hours after intubation. Results: Of 169 patients meeting criteria, 15 died and 10 developed VAP. The mortality odds ratio (OR) in patients receiving CXR was 0.10 (95% CI 0.01 to 0.98), and 0.11 (95% CI 0.03 to 0.46) in patients receiving early sedation. The mortality OR for patients with 3 or fewer interventions was 4.25 (95% CI 1.15 to 15.75) when compared to patients with 5 or more interventions. There was no significant relationship between VAP rate, ventilator days, or ICU LOS and any of the intervention groups. Conclusion: The performance of a CXR and early sedation as well as performing five or more vs. three or fewer post-intubation interventions in boarding adult ED patients was associated with decreased mortality.