title: How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations?
abstract: OBJECTIVE
  Out-of-hospital endotracheal intubation is a complex intervention. One strategy for improving the quality of a complex intervention is to limit the procedure to practitioners or agencies that meet minimum procedure experience standards. The system-level influence of such limits is unknown. We seek to determine how minimum endotracheal intubation experience standards influence the number and distribution of out-of-hospital endotracheal intubations.
  
  
  METHODS
  We used 2003 Pennsylvania statewide emergency medical services (EMS) data. We included endotracheal intubations that could be attributed to a valid rescuer, EMS agency, and minor civil division. We calculated the total number of endotracheal intubations performed across the state. We calculated the absolute and relative changes in total, cardiac arrest, nonarrest, pediatric, and trauma endotracheal intubation when the procedure was limited to on-scene rescuers meeting minimum endotracheal intubation experience standards, ranging from zero to 20 annual endotracheal intubations. We evaluated the same relationships when the procedure was limited to EMS agencies meeting minimum endotracheal intubation experience standards, ranging from zero to 200 annual endotracheal intubations. We evaluated these relationships with line plots and geographic information system maps.
  
  
  RESULTS
  During the study period there were 11,771 endotracheal intubations (7,854 cardiac arrest, 3,917 non-arrest, 1,325 trauma and 561 pediatric endotracheal intubations). Limiting endotracheal intubations to rescuers with at least 3, 5, 10, and 15 endotracheal intubations per year would result in relative endotracheal intubation reductions of 12%, 32%, 79%, and 93%, respectively. Limiting endotracheal intubations to EMS agencies with at least 20, 30, 50, 100, and 150 endotracheal intubations per year would result in relative endotracheal intubation reductions of 15%, 27%, 41%, 65%, and 73%, respectively. Cardiac arrest endotracheal intubations would exhibit the largest absolute reduction.
  
  
  CONCLUSIONS
  Minimum endotracheal intubation experience standards would result in absolute and relative reductions in total and subgroup endotracheal intubations. These findings provide vital perspectives about the system-wide organization of out-of-hospital airway management.
authors.affiliation: Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA. wanghe@upmc.edu
authors.forename: Henry E
authors.initials: HE
authors.lastname: Wang
authors.forename: Benjamin N
authors.initials: BN
authors.lastname: Abo
authors.forename: Judith R
authors.initials: JR
authors.lastname: Lave
authors.forename: Donald M
authors.initials: DM
authors.lastname: Yealy
mesh_terms: D002983:Clinical Competence; D004632:Emergency Medical Services / Q000592:standards*; D004634:Emergency Medical Technicians; D006801:Humans; D007442:Intubation, Intratracheal / Q000592:standards*; D010414:Pennsylvania