Variation in Intensive Care Unit Intubation Practices in Pulmonary Critical Care Medicine Fellowship

Background: Endotracheal intubation in the intensive care unit (ICU) is a high-risk procedure. Competence in endotracheal intubation is a requirement for Pulmonary and Critical Care Medicine (PCCM) training programs, but fellow experience as the primary operator in intubating ICU patients has not been described on a large scale. Objective: We hypothesized that significant variation surrounding endotracheal intubation practices in medical ICUs exists in U.S. PCCM training programs. Methods: We administered a survey to a convenience sample of U.S. PCCM fellows to elicit typical intubation practices in the medical ICU. Results: Eighty-nine discrete U.S. PCCM and Internal Medicine Critical Care Medicine training programs (77% response rate) were represented. At 43% of programs, the PCCM fellow was “always or almost always” designated the primary operator for intubation of a medical ICU patient, whereas at 21% of programs, the PCCM fellow was “rarely or never” the primary operator responsible for intubating in the ICU. Factors influencing this variation included time of day, hospital policies, attending skill or preference, ICU census and acuity, and patient factors. There was an association between location of the training program, but not program size, and whether the PCCM fellow was the primary operator. Conclusion: There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.