Intubation exposure associated with first-pass success – understanding practitioner-related characteristics in South African EMS

Endotracheal intubation is a critical life-saving intervention in prehospital emergency care, yet evidence supporting its safe implementation by prehospital practitioners in lower- to middle-income countries remains limited. First pass success (FPS) rates serve as a key process quality indicator, potentially influenced by practitioner-specific factors including clinical experience and procedure exposure. Differentiation between these two distinct measures is critical in understanding their impact on FPS. To describe the association between practitioner experience and intubation procedure exposure, and first-pass success rates during prehospital endotracheal intubation. We conducted a retrospective review of all prehospital intubations performed by practitioners of a public Emergency Medical Service in South Africa between January 2022 and December 2023. Data were extracted from the EMS case registry, which included integrated Computer Aided Dispatch and electronic Patient Care Record systems. Multivariate logistic regression analysis was used to assess associations, with mixed-model logistic regression identifying practitioner variability. Among 530,371 primary case activations, a total of 236 intubations were performed by 40 prehospital practitioners during the study period. The overall FPS rate was 80.9% (95% CI: 75.9–86.0%). Practitioner experience ranged from 0 to 14 years (mean 5.7 ± 3.5 years), with procedure exposure ranging from one to 55 intubations (mean 5.9 ± 11.2 intubations). Procedure exposure showed a statistically significant positive association with FPS (OR = 1.020, 95% CI: 1.000–1.040, p < 0.05). However, clinical experience showed no statistically significant association with FPS (OR = 0.940, 95% CI: 0.850–1.030, p = 0.190), while practitioners with zero to three years of experience demonstrated one of the highest FPS rates (83.33%). This study reveals a significant association between intubation procedure exposure and first-pass success rates in prehospital intubations, while practitioner experience demonstrated a non-significant association. These findings highlight the importance of continuous professional development in South African prehospital airway management and reinforce the imperative for sustained commitment to clinical excellence as a driver of system growth and improvement.