Airway/original research
Procedural Experience With Intubation: Results From a National Emergency Medicine Group

https://doi.org/10.1016/j.annemergmed.2019.04.025Get rights and content

Study objective

Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation performed by emergency physicians in a national emergency medicine group.

Methods

Using data from a national emergency medicine group (135 emergency departments [EDs] in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations).

Results

We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016). Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6).

Conclusion

These findings provide insights into the frequency with which emergency physicians perform intubations.

Introduction

Intubation is a critical procedure in acutely ill and injured patients and a central skill in emergency medicine training. Improper performance of intubation can result in complications.1, 2, 3 Furthermore, emergency airway cases are often complex and involve critically ill patients. Intubation skill acquisition and maintenance requires mentored teaching and continuing practice.4 In controlled settings, 20 to 50 intubation attempts are suggested as sufficient to develop competence.5, 6, 7 However, other work suggests that up to 250 intubations are required for emergency physicians to become proficient with this procedure in cardiac arrest patients.8 Although previous multicenter studies have examined emergency department (ED) intubation processes, these were predominantly performed at academic centers, and the frequency of these procedures, especially in community EDs, is unknown.9

Editor’s Capsule Summary

What is already known on this topic

Intubation is a core procedure in the emergency department.

What question this study addressed

How often do emergency physicians perform intubation?

What this study adds to our knowledge

In this series of 53,904 intubations performed by 2,108 emergency physicians in a national practice group, practitioners performed a median of 10 intubations per year (interquartile range 5 to 17). One fourth of emergency physicians performed 4 or fewer intubations per year.

How this is relevant to clinical practice

These results shed light on the intubation procedural frequency in contemporary emergency medicine practice. Additional methods are needed for ascertaining intubation proficiency and defining minimum experience thresholds.

Studies of complex medical procedures suggest that procedural frequency influences patient outcomes. It is generally assumed that clinical practice is sufficient to maintain proficiency with critical procedures such as intubation. However, existing data on the incidence of ED intubations, especially in the community setting, are limited. Understanding the frequency of intubations is potentially important in efforts to optimize quality and competence in clinical emergency airway management.

We sought to evaluate the incidence of intubation by emergency physicians in a national emergency medicine group.

Section snippets

Study Design and Setting

We performed a retrospective longitudinal study using data from a national emergency medicine group (US Acute Care Solutions). This study was approved by the Allegheny Health Network institutional review board.

During the study period, US Acute Care Solutions provided physician services at 135 EDs in 19 states. The group maintains a data set of all clinical ED encounters handled by group physicians. The curation of the study data set has been previously described.10 In summary, the group

Characteristics of Study Subjects

A total of 53,904 intubations performed by 2,108 emergency physicians at 135 facilities were included. These included 53,265 intubations performed by 2,022 emergency physicians working in 124 general EDs, 639 intubations performed by 121 emergency physicians working in 6 pediatric EDs, and 0 intubations performed by 91 emergency physicians in 5 freestanding EDs or urgent care centers during the study period. Of the 135 facilities, 11% (n=15) were trauma centers and 11% (n=15) were teaching

Limitations

Our study has several limitations. This is an administrative data set and thus dependent on coder accuracy for documenting procedure performance. However, as noted above, this coding on direct chart review appears accurate. We manually reviewed multiple charts for accuracy, including disposition, in-house codes, and extremes of ages, to ensure the validity of the data. We were unable to determine performance details of the intubations (eg, number of attempts required to perform the intubation,

Discussion

In this study, annual intubation incidence varied among emergency physicians, with a median of 10 per year, and approximately one quarter of emergency physicians performed fewer than 5 annual intubations. Intubation is a prominent procedure in emergency medicine practice. Our study provides new national insights of intubation performance in general EDs.

Our results do not indicate the minimum number of intubations necessary for emergency physicians to acquire or maintain proficiency. Proficiency

References (18)

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Cited by (19)

  • The Ethics of Procedural Education Under Pandemic Conditions

    2022, Journal of Emergency Medicine
    Citation Excerpt :

    From a pragmatic standpoint, at many academic medical centers, senior residents (i.e., postgraduate years 3/4) are the most facile laryngoscopists in the ED, thanks in part to the fact that many of them will have had the benefit of ED intubations under the supervision of multiple attending physicians, as well as significantly more recent experience as primary laryngoscopists compared with academic attending physicians. Although some attending physicians who spend a significant portion of time in community practice may be extremely capable laryngoscopists, the same cannot be said for academic faculty uniformly (21). Some older attendings may also be at increased risk of mortality from infection by virtue of their age.

  • Optimal Airway Management in Cardiac Arrest

    2020, Critical Care Clinics
    Citation Excerpt :

    The investigators found that ETI performance at the provider level varies widely in any given year (minimum 0 and maximum 109 ETIs) with a median of 10 (interquartile range 5–17) ETIs per year.26 ETI also is performed infrequently by some ED providers, with approximately 1 in 4 providers performing few than 5 ETIs per year.26 These numbers represent ETI for all conditions.

  • Critical procedure performance in pediatric patients: Results from a national emergency medicine group

    2020, American Journal of Emergency Medicine
    Citation Excerpt :

    The performance of these procedures is often required in emergency departments (ED), including general EDs that care for both adult and pediatric patients, pediatric EDs, and potentially freestanding EDs and urgent care centers, which are separate from a hospital. Although it is generally assumed that residency training and clinical practice alone is sufficient to ensure and maintain procedural skills, many critical procedures such as ETI in adult ED patients are infrequently performed by many practicing emergency physicians [11]. Understanding the frequency of these procedures is important in efforts to optimize quality and competence while ensuring EDs are prepared for critically ill pediatric patients.

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Please see page 787 for the Editor’s Capsule Summary of this article.

Supervising editor: Henry E. Wang, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

Author contributions: JNC, JMP, AC, and AV conceived the study. KM oversaw the detailed chart quality control and data extraction described. MZ performed the statistical analysis of the study. JNC, MZ, AC, and AV drafted the article. All authors conducted a critical review and revision of the article. AV takes responsibility for the paper as a whole.

All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Carlson is funded by the American Heart Association.

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