Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Endotracheal intubation (ETI) is a life-saving procedure commonly performed in emergency departments (ED). Prior research has demonstrated significant variability in ETI experience, practices, and outcomes across EDs. Health systems often include a mix of ED environments, from large academic hospitals to community-based and freestanding EDs. However, little is known about how ETI experiences and outcomes vary within a single health system. Our objective in this study was to compare first-attempt success across three EDs representing different practice environments but within one health system.

Methods: This retrospective observational study used institutional data from 1,659 ETI events between November 2021–January 2025 to compare ETI-related outcomes across three EDs representing a spectrum of settings: an academic Level I trauma center (A); a community teaching hospital (B); and a nonteaching community site (C). Our primary outcome measure was first-attempt success. We also assessed adverse airway outcomes and ETI-related patient and procedural characteristics. Chi-square tests evaluated the association of ETI-related outcomes and hospital sites.

Results: Annual ED volumes were approximately 82,000 (A), 64,000 (B), and 49,000 (C), with respective ETI encounters per 1,000 patients of 5, 2, and 0.4. The community teaching hospital had the highest first-attempt success rate of 90.2% (B: 331/367; 95% CI, 87.2-93.2), followed by the academic center with 84.6% (A: 1038/1227, 95% CI, 82.6-86.6), and then by the nonteaching community site with 78.5% (C: 51/65; 95% CI, 68.5-88.5) (P = .01). Adverse airway outcomes occurred in 10.5% of ETIs and did not vary significantly between sites (A: 139/1,227 [11.3%]; B: 29/367 [7.9%]; C: 6/65 [9.2%], P = .16). The most common indication was airway protection, followed by altered mental status and cardiopulmonary arrest for all three sites. Trainees performed the majority of ETIs at hospital A (1,096/1,227; 89.3%), while attending physicians predominated at B (295/367; 80.4%) and C (64/65; 98.5%).

Conclusion: We found significant variation in first-attempt success between the three ED sites, although overall success and adverse airway outcomes were comparable. These findings suggest that first-attempt success may be impacted by factors such as patient differences, role and training level of laryngoscopists, and inherent site-level differences such as patient volume and acuity.