Association Between Operator Experience and Procedural Outcomes of Tracheal Intubation in the Emergency Department and ICU - 23/08/25

Doi : 10.1016/j.annemergmed.2025.07.008

Alexander T. Clark, MD ^a,^⁎ , Wade Brown, MD ^b, Michael J. Ward, MD, MBA, PhD ^c,^d,^e, Jason C. Brainard, MD ^f, Joseph M. Brewer, DO ^g, Brian E. Driver, MD ^h, John P. Gaillard, MD ^i,^j, Sheetal Gandotra, MD ^k, Shekhar Ghamande, MD, FCCP ^l, Kevin W. Gibbs, MD ^m, Adit A. Ginde, MD ⁿ, Joanne W. Hudson, MSc, PA-C FCCP ^o, Christopher G. Hughes, MD, MS FCCM ^p, David R. Janz, MD ^q, Aaron M. Joffe, DO ^r, Akram Khan, MD ^s, Aaron J. Lacy, MD ^t, Andrew J. Latimer, MD ^u, Steven H. Mitchell, MD ^u, David B. Page, MD, MSPH ^k, Matthew E. Prekker, MD, MPH ^h, Todd W. Rice, MD, MSc ^v, Derek W. Russell, MD ^k,^w, Wesley H. Self, MD, MPH ^c, Lane M. Smith, MD, PhD ^x, Susan B. Stempek, MBA, MMSc, PA-C ^y, Derek J. Vonderhaar, MD ^z, Li Wang, MS ^aa, Jason R. West, MD ^bb, Heath D. White, DO, MS ^l, Micah Whitson, MD ^k,^cc, Matthew W. Semler, MD, MSc ^v, Jonathan D. Casey, MD, MSc ^v
^a Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
^b Division of Pulmonary and Critical Care Medicine, Meharry Medical College, Nashville, TN
^c Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
^d Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
^e Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN
^f Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
^g Division of Critical Care Medicine, Integris Baptist Medical Center, Oklahoma City, OK
^h Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
ⁱ Department of Anesthesiology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
^j Department of Emergency Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
^k Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
^l Division of Pulmonary, Critical Care, and Sleep Medicine, Baylor Scott & White Health, Temple, TX
^m Division of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
ⁿ Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
^o Division of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, Burlington, MA
^p Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
^q Division of Pulmonary and Critical Care Medicine, University Medical Center of New Orleans, New Orleans, LA
^r Department of Anesthesiology, Valleywise Health Medical Center, Creighton School of Medicine, Phoenix, AZ
^s Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR
^t Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
^u Department of Emergency Medicine, University of Washington, Seattle, WA
^v Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
^w Veteran’s Affairs Medical Center, Pulmonary Section, Birmingham, AL
^x Division of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Atrium Health Carolinas Medical Center, Charlotte, NC
^y Division of Pulmonary & Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA
^z Division of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, LA
^aa Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
^bb Department of Emergency Medicine, New York City Health + Hospitals | Lincoln, Bronx, NY
^cc Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 23 August 2025

Abstract

Study Objectives

Complications are common during emergency tracheal intubation. Although graduate medical education in emergency medicine and critical care mandate competency in this procedure, thresholds for proficiency are poorly defined. We evaluated the relationship between the operator performing intubation and complications of emergency tracheal intubation.

Methods

We performed a secondary analysis of data from 8 multicenter randomized trials of critically ill adults undergoing emergency tracheal intubation in an emergency department or ICU in the United States. We examined the relationship between an operator’s prior intubating experience and procedural outcomes, including successful intubation on the first attempt and lowest oxygen saturation.

Results

Among 2,839 intubations with data on prior intubating experience of the operator, 1,863 (65.6%) were by critical care medicine clinicians and 739 (26.0%) by emergency medicine clinicians. The median number of reported previous intubations by clinicians was 56.0 (interquartile range, 32 to 100). Greater intubation experience was associated with an increased odds of successful intubation on the first attempt (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.30 to 2.36; P<.001) and increased lowest oxygen saturation (OR 1.45; 95% CI, 1.21 to 1.73; P<.001). Learning curves suggested a plateau effect between 35 and 50 intubations.

Conclusion

For tracheal intubations performed in an emergency department or ICU, intubating experience is associated with improved procedural outcomes, reaching a plateau outcome after a mean 35 to 50 previous intubations.

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Keywords : Intubation, Tracheal, Education, Medical, Graduate, Procedural training, Learning curve

Plan

Introduction

Background

Importance

Goals of This Investigation

Methods

Study Design

Setting and Selection of Participants

Baseline Characteristics

Study Outcomes

Limitations

Discussion

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Nicholas M. Mohr, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: ATC, WB, MWS, JDC: Study concept and design. All authors: Acquisition of data; analysis and interpretation of data; critical revision of the manuscript for important intellectual content. ATC, WB, MJW, MWS, JDC: Drafting of the manuscript. Senior authors JDC and MWS contributed equally. ATC takes responsibility for the paper as a whole.
	Data sharing statement: The deidentified data set and data dictionary used for each trial is available for sharing on request. Details regarding the requirements for and mechanism of sharing request are included as part of each initial trial publication. For additional information, contact Dr. Jonathan Casey at jonathan.d.casey@vumc.org.
	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). ATC received funding support from the EMF/EMRA Residency Research Grant 2023-2024. SHM received funding support from SharpMed. DWR was supported by NHLBI/NIH K08HL148514. AJL was supported by the DOD. The authors have declared that no competing interests exist.