title: Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan.
abstract: BACKGROUND
  A reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway.
  
  
  METHODS
  This historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation.
  
  
  RESULTS
  Of the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1-5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1-8.4; p = 0.034).
  
  
  CONCLUSIONS
  In this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway. These data imply the need for more attentive hospital care during nights and weekends.
authors: Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan. windmill@fmu.ac.jp.|Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan. windmill@fmu.ac.jp.
authors: Yuko
authors: http://orcid.org/0000-0002-5953-3042
authors: Y
authors: Ono
authors: Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan.
authors: Takuya
authors: T
authors: Sugiyama
authors: Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan.
authors: Yasuyuki
authors: Y
authors: Chida
authors: Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan.
authors: Tetsuya
authors: T
authors: Sato
authors: Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan.
authors: Hiroaki
authors: H
authors: Kikuchi
authors: Department of Head and Neck Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan.
authors: Daiji
authors: D
authors: Suzuki
authors: Department of Otolaryngology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
authors: Masakazu
authors: M
authors: Ikeda
authors: Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.|Fukushima Global Medical Science Center, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
authors: Koichi
authors: K
authors: Tanigawa
authors: Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan.
authors: Kazuaki
authors: K
authors: Shinohara
mesh_terms: D000328:Adult; D039602:After-Hours Care; D000368:Aged; D058109:Airway Management; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D006764:Hospitals, Community; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects*; D007564:Japan; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014947:Wounds and Injuries
keywords: Airway management; Comminuted facial trauma; Difficult airway management; Fatal complication; Inhalational burn; Penetrating neck injury