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Written by Aaron Lacy
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Review of tracheal intubations (TIs) performed in pediatric ICUs found advanced practice registered nurses (APRNs) had a lower first attempt success compared to doctors and respiratory therapists.
Who should be intubating sick kids?
11,012 TIs from the NEAR4KIDS registry were included in this retrospective study. APRNs were compared to other clinicians (residents, fellows, attendings, hospitalists, and respiratory therapists). 15% (1,626) of TIs were done by APRNs. APRNs were more likely, compared to other clinicians, to intubate children <1 year of age and those with cardiac disease.
APRNs had an overall lower rate and lower odds of success in first attempt TI vs other clinicians: 62.5% vs 70.7% (95%CI -10.7 to -5.6%, p<0.0001); aOR 0.70 (95%CI 0.62-0.79). APRN first attempt success increased with experience, measured by years of practice, not TI attempts: <1, 54.2%; 1-5, 59.4%; 6-10, 67.6%; >10, 63.1%, p=0.021.
There was no difference in rates of TI adverse events, OR 1.23 (95%CI 0.97-1.57, p<0.001) between APRNs and non-APRNs. Breaking down first attempt success rate by non-APRN, residents (48.6%) and hospitalists (59.5%) had lower first attempt success than APRNs. Attending physicians (80.4%), fellows (71.2%), and respiratory therapists (64.1%) had higher first attempt success compared to APRNs.
How will this change my practice?
In their discussion, the authors state, “TIs… are a relatively infrequent occurrence. Therefore, sharing the opportunity of their occurrence, particularly between critical care fellows and APRNs is essential.” Not only is TI of the critically ill child an infrequent event, the number of TIs in ICUs is decreasing secondary to advances in non-invasive oxygen and ventilation methods. As the number of intubation opportunities decreases, opportunities for training and skill maintenance do as well. This is highlighted nicely in a response to this article by Schwartz and colleagues. APRNs are integrated into pediatric ICUs across the country and play an important role in the care of ill children – that is not in question. The question here is who should be intubating; and if in a training center, to whom should the learning opportunity go? Does spreading out this infrequent procedure between more providers help or hurt patients? While I have my opinion, in my role I will not have to answer this question. For those who do make these decisions, this article gives plenty to ponder.
Source
Tracheal Intubation by Advanced Practice Registered Nurses in Pediatric Critical Care: Retrospective Study from the National Emergency Airway for Children Registry (2015-2019). Pediatr Crit Care Med. 2024. Feb 1;25(2):139-1466. Doi: 10.1097/PCC.0000000000003386.
I eagerly await the incredibly civilized and not at all polarized discussion here.
The greatest “takeaway” in the article (in my opinion) was that there is a direct relationship between experience and first pass success. This is not groundbreaking by any means. With such heterogeneous education in APRN programs across the U.S., on-the-job training becomes more important than ever for APRNs. Essentially, one must ask themselves, “do I want to pay a full salary to an APRN to teach them to intubate? or do I want to train a resident physician?” In other words, a graduated APRN is not labeled as a “trainee” and yet, so often, they “compete” in the hospital environment with residents for experience as such. In my opinion, as someone who intubates patients regularly, I would rather train someone who is getting paid to be trained and will become my replacement – i.e, a physician. I would not give an experience to an APRN so long as there is a resident physician within arms reach. I respect and appreciate the role of the APRN but I see that role to be very different from that of the physician.