3.3 Tracheal Intubation

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Description of Indicator

Relationship to Quality  Medical care should be safe
Type of Indicator Hospital process, Hospital level
Proposed Data Source ED Records, Trauma Registry
Definition All injured patients age 18 years and older with documented decreased level of consciousness (GCS < 9) in the ED AND with successful insertion of endotracheal tube in the ED
Numerator All injured patients age 18 years and older with documented decreased level of consciousness (GCS < 9) in the ED AND with successful insertion of endotracheal tube in the ED
Denominator Injured patients age 18 years and older with decreased level of consciousness (GCS < 9) in the ED
Benchmark Not specified at present
Risk Adjustment Not specified at present


This indicator is intended to monitor endotracheal intubation for injured patients with a decreased level of consciousness in the ED.

Panel Review
A key question panelists discussed was whether including this indicator would be beneficial given its current wide utilization, but limited supporting evidence.
As for implementation, panelists emphasized key issues that would need to be addressed. It was noted that setting a time period for this indicator (e.g. intubation within 10 minutes) may not be clinically relevant or practical from a measurement perspective. Conversely, inclusion of severity of injuries and shock as indications for intubation are not practical. For successful implementation and effectiveness of this indicator, it was discussed that the indicator should address reduced level of consciousness at any time during the ED stay, not just on admission or discharge. In addition, panelists highlighted that accounting for prehospital intubation may be important.

Trauma Center Review
It was suggested that it may be important to collect the reason why intubation was not performed in patients where the indicator definition suggests it was indicated. The trauma centers expressed that this indicator may require additional resources in order to ensure compliance and to review information. Current practices may not capture the necessary information (e.g. Trauma Registry only records initial observations and may not capture patients who deteriorate during ED).

Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: Three studies showed no association between the quality indicator and hospital mortality14,15,36. Two studies demonstrated that implementation of a trauma quality improvement program that included the quality indicator was associated with reduced hospital mortality44,45.
Reliability: No studies identified.
Risk Adjustment: No studies identified.
Utilization: Endotracheal Intubation associated indicators are used by a large number of trauma centers: USA 74% (148/200), Canada 97% (34/35), Australasia 67% (8/12).
A 12-month prospective study was undertaken to observe current practice and to determine if a GCS of < 9 is a useful parameter to predict the need for airway protection in poisoning. An initial GCS of < 9 had a sensitivity of 90% and specificity of 95% for predicting the need for intubation46.


American College of Surgeons Committee on Trauma proposed the indicator Comatose Trauma Patient Leaving the ED before Mechanical Airway Established2.


2. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American College of Surgeons; 2006.
14. Nayduch D, Moylan J, Snyder BL, Andrews L, Rutledge R, Cunningham P. American College of Surgeons trauma quality indicators: an analysis of outcome in a statewide trauma registry. J Trauma. 1994;37(4):565-573; discussion 573-565.
15. Copes WS, Staz CF, Konvolinka CW, Sacco WJ. American College of Surgeons audit filters: associations with patient outcome and resource utilization. J Trauma. 1995;38(3):432-438.
36. Willis CD, Stoelwinder JU, Cameron PA. Interpreting process indicators in trauma care: construct validity versus confounding by indication. Int J Qual Health Care. 2008;20(5):331-338.
44. Chadbunchachai W, Saranrittichai S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai. 2003;86(1):1-7.
45. Chadbunchachai W, Sriwiwat S, Kulleab S, Saranrittichai S, Chumsri J, Jaikwang P. The comparative study for quality of trauma treatment before and after the revision of trauma audit filter, Khon Kaen hospital 1998. J Med Assoc Thai. 2001;84(6):782-790.
46. Chan B, Gaudry P, Grattan-Smith TM, McNeil R. The use of Glasgow Coma Scale in poisoning. J Emerg Med. 1993;11(5):579-582.