Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia

Ann Emerg Med. 2018 Sep;72(3):272-279.e1. doi: 10.1016/j.annemergmed.2018.01.044. Epub 2018 Mar 9.


Study objective: Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation.

Methods: We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt.

Results: The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO2, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO2 values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]).

Conclusion: In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.

Publication types

  • Observational Study

MeSH terms

  • Allied Health Personnel / standards
  • Blood Pressure Determination / methods
  • Blood Pressure Determination / standards
  • Controlled Before-After Studies
  • Electrocardiography
  • Emergency Medical Services / methods*
  • Emergency Medical Services / standards
  • Female
  • Humans
  • Hypoxia / prevention & control*
  • Intubation, Intratracheal / methods*
  • Intubation, Intratracheal / standards
  • Male
  • Middle Aged
  • Oximetry / methods
  • Oximetry / standards
  • Oxygen / blood
  • Patient Care Bundles / methods*
  • Patient Care Bundles / standards
  • Patient Care Planning
  • Patient Positioning / methods
  • Prospective Studies
  • Quality Improvement
  • Texas
  • Treatment Outcome


  • Oxygen