A retrieval team was more likely to be required for intubation of critically unwell patients in the most rural and remote areas of Queensland, Australia. This corresponds with services removed from the coastal and city regions. In the MMM remoteness category 5-7 (Distribution Priority Areas), nearly half of patients were intubated by a retrieval team. Patients in urban and regional areas were far more likely to be intubated by the local team prior to transfer.
A number of factors may influence this finding. Medical and nursing staff in MMM 5-7 facilities may be less likely to have current advanced airway skills and may be less comfortable to proceed with intubating patients when it is safer to await the arrival of the retrieval team.(11) Smaller facilities are more likely to be nurse only clinics or rural hospitals with doctors less experienced with intubation.(12, 13) Patients may also be intubated for transport considerations such as anticipated clinical course, risk of deterioration in flight and difficulties associated with managing an unprotected airway.(6) It is also a consideration that in remote areas, deterioration of the patient’s condition by the time a retrieval team arrive may necessitate intubation.(14)
While this finding is not unexpected, it reinforces the critical role played by retrieval teams in supporting local hospital staff in more rural locations in Queensland. Services in regional and urban centres are more likely to be staffed with teams able to manage the process of intubation independent to a retrieval service.(11)Our results suggest that in remote settings, the hospital teams often wait for a retrieval team, , despite the increased distance and time taken for a team to reach these locations, a finding supported in other recent literature.(2)The findings support the current coverage and provision of critical care in the state.
When comparing the patients intubated by the retrieval team to those intubated by the local team, advancing age was associated with the retrieval team intubating the patient. It is difficult to determine the reasoning for this finding, which is likely to be multifactorial. The decision to intubate any patient involves a risk/benefit assessment, and advancing age is likely to adjust the balance.(15) The frequency of chronic disease and polypharmacy increases with advancing age, further complicating the decision to intubate. The arrival of the retrieval team, and the additional of current airway skills may then readjust the risk assessment, including consideration of the possibility of airway compromise in flight. The process of intubation in a helicopter or aeroplane is high risk and should be avoided.(16)
Experience and literature suggests that reluctance to intubate might occur more with children.(2) While some paediatric intubations were included in this study, it should be noted that a significant proportion of paediatric retrievals in Queensland are managed by a specialised paediatric retrieval team and not included in this data. Nonetheless, our data suggests that local teams will intubate paediatric cases when required prior to the arrival of the retrieval team.
Missions involving patient intubation were equally likely to occur during the day or night and time of day was not associated with the retrieval team intubation. It is recognised that most hospitals, particularly in tertiary centres, run a reduced service at night. Our data suggests that in more rural and remote regions, particularly MMM 5-7, time of day does not impact significantly on a retrieval team being required for intubation.(17)
The most common diagnostic classifications were: cardiovascular, respiratory, major trauma, neurological, and the composite ‘injuries, poisons, toxicology and drugs.’ This is in keeping with existing literature.(5) In the cohort of all intubated and transferred patients, no diagnosis was associated with an increased likelihood of the retrieval team being required for intubation. In fact, patients requiring intubation due to ‘injuries, poisons, toxicology and drugs’ remained significantly less likely to be intubated by the retrieval team in multivariable modelling and regardless of remoteness region. This suggests that local teams are prepared to intubate irrespective of presentation when required.
It is of note that while there were instances of intubation failure in both the retrieval team cohort and the local cohort, these were low in number and not of significance. This again supports the current model of care in Queensland, and reinforces the work done in particular by RSQ. RSQ provides critical care support to clinics and facilities throughout Queensland, including through the use of telehealth. RSQ is able to guide and advise clinicians in real time during critical procedures such as intubation, and this process has been streamlined with the state-wide implementation of a Standardised and Safe Intubation Package (SSIP) that is available to all Emergency Departments in Queensland Health. The clinical and technological support afforded by telehealth is crucial and demonstrates a tangible and real benefit to patients in remote communities that would otherwise be less well supported at times of need.(18, 19)
In the multivariable analysis of all patients, only the MMM 5-7 category remained statistically significant as a predictor for the retrieval team intubating. Therefore, all factors considered, retrieval teams are important in the support of rural and remote locations. This finding supports the practice of prioritising the retrieval of patients from these locations, particularly where RSQ might anticipate a patient requiring intubation, or in the instance where a patient’s condition deteriorates in real time.
In the subgroup analysis of rural and remote patients alone, MMM 5-7 (DPAs), the group intubated by the retrieval team were significantly older that those intubated by the local team. For patients with the composite diagnosis ‘injuries, poisons, toxicology and drugs’, the retrieval team were significantly less likely to be involved in the intubation of these patients compared to the local team, a finding that persisted in the multivariable analysis. It is unclear why this composite diagnosis should favour earlier intubation by the local team.
Our findings are generalisable to other large states and countries where medical care is focused in tertiary centres, but a population distributed over large areas. This is the case for other states in Australia, and also for countries like the United States of America, Canada and more remote parts of the United Kingdom.(14) Preference should be given to a small hospital undertaking a critical procedure or caring for an unwell patient, over areas where staffing is likely to be better.
This was a retrospective study and as such cannot show causation. Biases are an inherent risk in retrospective reviews. Data were entered by the treating clinician and are thus open to bias. It should be noted that LRM operate a weekly audit of cases, and that all cases involving intubation are reviewed by senior consultants. The LRM governance team review the airway registry once a month.
This study focused on the demographic and diagnostic data surrounding intubated patients. It was beyond the scope of the work to analyse the specific process of intubation, and any errors or harm that may have occurred in this process. The authors sought more to obtain an overview of distribution of care. Extensive research already exists on the process and outcome of intubation itself.
The diagnostic classifications used in this study are a replica of the drop-down menu that doctors select when entering patient data into the AirMaestro clinical notes. As such, they contain composite diagnoses and may not represent the most effective way of grouping patients.
The authors only examined missions that involved LRM doctors. The ‘general’ retrieval teams that were not represented in this study include RFDS teams that operate out of RFDS Queensland Section Traditional Bases (Cairns, Mt Isa, Charleville). The total number of intubations performed by RFDS doctors from Traditional Bases are likely to be significantly less than those performed by LRM doctors, who work across a number of providers throughout the state including RFDS bases.
This study does not consider the specialised paediatric and neonate retrieval services that exist in the state and the missions they perform on this subset of patient groups, while noting recent publication in this area.(2)
This study gives an estimate of rural and remote intubations based on LRM doctor records for aeromedical services in Queensland, Australia. A more collaborative study involving the major providers of aeromedical retrieval teams in Queensland, including LRM, RFDS and the specialised paediatric and neonatal services would give more generalised information and could further aid RSQ/Queensland Health with health resource training and planning.
We also plan to perform a detailed review of the 131 cases where intubation was done by the retrieval team in an attempt to extract rationale for it not being performed by the local team. This review will expand to use data held by RSQ, which should capture the decision making that occurred prior to the team’s arrival.