title: Paramedic rapid sequence induction (RSI) in a South African emergency medical service: a retrospective observational study.
abstract: BACKGROUND
  Early access to critical care interventions may improve outcomes for severely ill and injured patients. South Africa (SA) faces the unique challenges of prolonged pre-hospital times and limited access to physicians. In 2008, the Health Professions Council of SA introduced paramedic rapid sequence induction (RSI), the gold standard critical care intervention for emergency airway management; however, the risk to benefit ratio in this context is unclear.
  
  
  OBJECTIVE
  We conducted a pilot study to identify if paramedic RSI in the SA pre-hospital care setting is effective and safe.
  
  
  METHODS
  We undertook a retrospective observational study of paramedic RSI performed by an emergency medical service, between 12 December 2009 and 12 December 2011.
  
  
  RESULTS
  Eighty-six RSIs were performed during the study period. No failed intubations were reported. Heart rate was significantly reduced from a median baseline value of 112 to 90 bpm, and oxygen saturations improved from 92% to 99% at handover following RSI. Nineteen patients (22%), however, had an adverse event (AE). Female patients (odds ratio (OR) 18.3; 95% confidence interval (CI) 3.46 - 99.38; p=0.001) and patients subsequently transported by helicopter (OR 7.24; 95% CI 1.44 - 36.32; p=0.016) remained independently associated with AEs after adjusting for confounders.
  
  
  CONCLUSIONS
  RSI performed by specially trained paramedics is effective in terms of self-reported success. However, the 1 in 5 AE rate highlights safety concerns. The importance of a robust clinical governance programme to identify problems, refine practice and improve the quality of care is underscored.
authors.affiliation: Inkosi Albert Luthuli Central Hospital, Durban, South Africa. mattgunning@rcsed.ac.uk.
authors.forename: Matthew
authors.initials: M
authors.lastname: Gunning
authors.forename: Zane
authors.initials: Z
authors.lastname: Perkins
authors.forename: Julia
authors.initials: J
authors.lastname: Crilly
authors.forename: Richard
authors.initials: R
authors.lastname: von Rahden
mesh_terms: D000328:Adult; D000369:Aged, 80 and over; D002675:Child, Preschool; D016638:Critical Illness / Q000453:epidemiology / Q000628:therapy; D004521:Educational Measurement; D004632:Emergency Medical Services / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D004634:Emergency Medical Technicians / Q000193:education / Q000458:organization & administration / Q000592:standards; D005260:Female; D057209:Hospital Rapid Response Team / Q000458:organization & administration*; D006801:Humans; D008297:Male; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D061214:Patient Safety / Q000706:statistics & numerical data; D010865:Pilot Projects; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology