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The Impact of Mandatory Minimums on Intubation

Review of: Henry E, Wang HE, Abo BN, et al: “How Would Minimum Experience Standards Affect the Distribution of Out-of-Hospital Endotracheal Intubations?” Annals of Emergency Medicine. 50:246-252, 2007

The Science
In this study, researchers reviewed the Pennsylvania state pre-hospital database for 2003 and tabulated the number of endotracheal intubations. They then examined the intubations to determine who performed them and how many were performed per EMT, as well as within the EMS agency. The question was: What would happen to intubation rates if they were limited only to individuals and agencies with different minimum intubations per year?

There were 11,998 successful intubations, of which they could attribute 11,771 to a particular individual, agency or geographic location. They included 7,854 cardiac arrest, 3,917 non-arrest, 1,325 trauma and 561 pediatric intubations. Air medical units performed 849 intubations. In the rural areas of Pennsylvania (minor civil divisions) 31.6 percent had no intubations performed.

3,442 rescuers performed the 11,771 intubations (range of 1_23 intubations per rescuer; median three). 370 EMS agencies performed intubations (range of 1_1,407 intubations per agency; median 17).

The researchers concluded that if endotracheal intubation were limited to rescuers performing a minimum of three, five, 10 and 15 per year, the relative overall reduction in intubations performed would be 12, 32, 79 and 93 percent, respectively. If intubation was limited to agencies with a minimum number of 20, 30, 50, 100 and 150 intubations, the overall reductions would be 15, 27, 41, 65 and 73 percent, respectively.

The Street
Endotracheal intubaton continues to be a controversial topic. How many tubes a year should you pass to be competent? This study is the first to look at a statistical model to determine the impact of setting mandatory minimums.

What is most interesting about this study is that the reductions in intubations would predominantly affect cardiac arrest. With the recent AHA changes and our growing understanding of the proper role of airway control and ventilation, the role of endotracheal intubation is questionable, and the overall reduction in intubation may not have a negative effect.

Unfortunately, this study only tracked successful intubations. There are no outcome data, so we don t know the clinical impact of any reduction in intubations..

While I believe that there should be some minimum number of intubations per year to be considered competent, I don t know what that number is. However, before a service decides to set that number, it is vital that they perform, statewide, the same level of scrutiny to their intubation rates as this study.
It would be very interesting to look more closely at the non-arrest and trauma intubations, determine where they occurred, and follow their clinical outcome. I suspect as we move forward, such studies will further refine the role of out-of-hospital intubation.


  1. Title of the article is misleading–I thought it was going to talk about having mandatory training and minimums established and how it was going to affect success rates of intubation. And while it is a nice data set to look at raw numbers, there is no application that an EMS administrator could build on that would help guide a) whether to intubate in your service or not and b) how to bridge any gaps. Accordingly, what is the value in this study? It appears to be merely a crunching of numbers. And only half of them–if you at least had the misses, you could then run a statistical analysis to see what correlation the volumes might have on success by individual or service.

  2. An addt’l limitation of this study/ article is how many attempts were need to achieve a “successful intubation”. For years Pierce County, WA has operated w/ a “minimum number of tubes per year” system for PMs to recertify. Just recently we switched to a “competency-based, education-driven” system for evaluating competency in advanced airway management that I believe does a better job of ensuring that our PMs are actually able to perform the skill well, not just perform. We’re not yet done w/ the first year, so I can’t comment on how effective we’ll be, if at all. Something to think about/ consider if your system just counts numbers… numbers don’t necessarily equal competence!

  3. There are some answers to the last question about outcomes like the study published at the Annals of Surgery :Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury.
    Do some research, I’m sure you’ll find some answers like this at the web.
    Doctor Chang did a lot of research about it, but, lately you’ll find the other aspects about the influence of intubation.
    Also, other choices are taking force as the non-invasive ventilatios as the CPAP with mask.

  4. 2003 Database, impressive. Is it not 2012?

  5. The issue is not with excluding PM’s that do not meet minimum intubation requirements, but rather forcing PM’s to have a certain number per year to remain competent when combined with the formerly mentioned style of competency based education. All this study seems to prove is that PM’s need access to other areas of the healthcare system (the OR) through a formal EMS system sponsored CE programs to intubate patients under the direction of an Anesthesiology practitioner. MD/DO, AA, CRNA or whatever. We PM’s could stand to learn a lot from such people.

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