Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care

Objective: Many EDs have begun to evaluate their airway performance. The first-pass success (FPS) rate is a commonly used marker of proficiency, and has been associated with rates of adverse events. The aim of this systematic review and meta-analysis is to quantify the ED FPS rates and summarise the rates of adverse events associated with endotracheal intubation. Methods: A structured literature search was performed through MEDLINE and EMBASE. Research published since 2000 was included if it prospectively collected data on all patients intubated in the ED and reported the FPS rates. Data on demographics, indication, FPS rates, adverse events, proportion by RSI and proportion by emergency medicine doctors were extracted. Pooled mean FPS rates were estimated using a random effects model. Results: The literature search generated 21 162 articles. Full-text review identified 16 publications for meta-analysis. This included a total of 42 081 intubations from 83 institutions, in 10 countries. The FPS rate was 84.1% (95% confidence interval [CI] 80.1-87.4] in the 'ED-All' group and 81.8% (95% CI 76.3-86.2) in the 'Trauma-Only' group. The incidence rates of commonly reported adverse events were hypoxia 6.4% (95% CI 2.5-11.9), hypotension 3.0% (95% CI 1.5-4.9), oesophageal intubation 3.5% ( 95% CI 2.3-4.9), greater than three attempts 0.8% (95% CI 0.4-1.4), cricothyrotomy 0.3% ( 95% CI 0.1-0.5) and periintubation cardiac arrest 0.6% (95% CI 0.2-1.0). Conclusion: Research published in the last 16 years shows a mean ED FPS rate of 84.1%. This represents the best available published data that can be used to benchmark emergency airway performance.