Prehospital Endotracheal Intubation Success Rates for Critical Care Nurses Versus Paramedics

Prehospital endotracheal intubation (ETI) is a lifesaving procedure with known complications. To reduce ETI-associated morbidity and mortality, organizations prioritize first-pass success (FPS). However, there are few data evaluating the association of FPS with clinician licensure.

We performed a retrospective chart review of all paramedic and nurse ETI attempts by a multi-state air and ground critical care transport service between January 1, 2008, and December 31, 2023. Our outcomes of interest were FPS and last-pass success (LPS). The exposure of interest was clinician license. We performed a multivariable logistic regression controlling for multiple common patient/operational confounders: age, sex, referring/procedure location, medical category, year, paralytic use, and proceduralist experience. As an exploratory analysis we assessed FPS by licensure and years of experience using time since first patient mission as a surrogate (<1 year, 1 to <2 years, 2 to <3 years, and 3+ years).

Of 171,804 encounters over the study period, 8,307 (4.8%) required ETI. Included encounters were mostly adult (≥18 years old; 91.0%), male (64.0%), and victims of trauma (57.4%). Most intubations were performed on primary retrieval (scene) missions (70.5%) with neuromuscular blockade (93.3%). Nurses and paramedics intubated with similar success on the first (88.8%; 95% confidence interval [CI] 87.9-89.8 vs. 89.7%; 95% CI 88.7-90.7) and last (97.4%; 95% CI 96.9-97.9 vs. 97.3%; 95% CI 96.7-97.8) attempts. Multivariable analysis revealed no significant difference between two groups for FPS (aOR 0.90; 95% CI 0.77-1.04]) or LPS (aOR 1.00; 95% CI 0.76-1.32). FPS was also similar for nurses (74.7%; 95% CI 69.8-79.7) and paramedics (80.6%; 95% CI 75.6-85.6) within the first year, and after 3 years of experience (91.6%; 95% CI 90.6-92.5 vs. 91.5%; 95% CI 90.5-92.6).

Critical care paramedics and nurses perform ETI with similar proficiency. In this analysis of 7,812 intubations, clinician licensure was not associated with FPS nor LPS after controlling for multiple common confounders. Further research evaluating training schemes especially in early years of experience is needed.