Underuse of Rapid Sequence Intubation Outside the Emergency Department: Insights from Emergency Physicians‒a Preliminary, Retrospective Observational Study

Objective: Rapid sequence intubation (RSI) involves the administration of induction agents and neuromuscular blockers before endotracheal intubation (ETI). However, RSI seems to be underutilized outside emergency departments (ED). We compared RSI adoption rates and ETI outcomes outside and within EDs and investigated whether RSI adoption affected ETI outcomes outside EDs.

Methods: This retrospective study included adults who underwent emergency ETI outside the operating room at a university hospital between March 2022 and February 2023. The exclusion criteria included CPR, intentional RSI avoidance, and tube exchange via the introducer. The primary outcome was the first-pass success rate. Secondary outcomes included multiple (≥3) attempts, prolonged (>5 min) ETI, and complications. The association between RSI adoption and outcomes outside the ED was assessed using multivariable logistic regression.

Results: A total of 490 ETI cases were included: 290 males, 68.3±14.7 y. Cases outside ED (n=286) received less RSI than cases at ED (n=204): 12.6% vs. 86.8%, p<0.001. They showed less first-attempt success (62.2% vs. 88.2%) and more multiple attempts (11.5% vs. 2.0%), total time of ETI (8.4±8.3 vs. 2.5±2.5 min, p<0.001), and complications (32.2% vs. 19.6%, p=0.003). However, multivariable logistic regression revealed no significant association between RSI adoption and outcomes outside the ED: odds ratio 1.74 [95% CI: 0.783-3.84], 0.167 [0.022-1.30], 1.04 [0.405-2.69]), and 1.50 [0.664-3.40]), respectively.

Conclusion: Outside the ED, RSI adoption was lower and ETI outcomes were poorer than those within the ED. However, no association was found between RSI adoption and ETI outcomes outside the ED.