How Do Emergency Physicians Define and Document First Attempt Success When No Definition Is Provided? A Survey Study

Endotracheal intubation (ETI) is a high‐risk procedure performed by emergency physicians (EPs) with potentially severe physiologic adverse events, including hypoxia, hypotension, and cardiac arrest [1]. Completing the procedure on the first attempt, termed first attempt success (FAS; sometimes referred to as “first pass success”), has been associated with lower rates of adverse outcomes compared with intubations requiring multiple attempts [2].

Given this association with patient‐centered outcomes, FAS has been widely used as a benchmark outcome in airway‐related research for decades, often as a primary outcome. Despite its widespread use, there is no universal consensus on what defines FAS. Historically, FAS has most commonly been defined as successful insertion of an endotracheal tube (ETT) during a single laryngoscope blade insertion [3]. In a secondary analysis of two major multicenter randomized airway trials (BOUGIE and PREPARE II), investigators from the Pragmatic and Critical Care Research Group (PCCRG) demonstrated that applying a stricter definition of FAS (one laryngoscope blade insertion followed by a single insertion of an ETT with stylet or an endotracheal tube introducer, with subsequent tube passage) resulted in a significant reduction in reported FAS rates [4]. When this stricter definition of FAS was applied, they also found ETI attempts that met this definition had a median duration of intubation 35 s shorter than those which did not, with all point estimates pointing toward lower complication rates. To better represent procedural performance in relation to patient outcomes, the authors recommended that future ETI research define FAS as one laryngoscope blade insertion followed by one ETT with stylet or ETT introducer insertion.

Unlike these trials, in which FAS was collected by a trained observer, much of airway research over the last two decades has relied on retrospective chart review or airway research registries, which often depend on accurate and consistent proceduralist self‐reporting. Retrospective chart review relies solely on proceduralist self‐reporting, most often through documentation of the procedure note in the Electronic Medical Record (EMR). If not provided with a predetermined definition of FAS when entering procedural data into the EMR this creates the possibility of introducing measurement error secondary to an individual's own bias and personal definition of FAS, which could add a significant limitation to retrospective chart review research. A higher level of research is the airway registry, in which data is prospectively entered. However, there may be limitations to some airway registries. In a 2023 scoping review, Meulendyks and colleagues found that among 22 airway registries some (e.g., the National Emergency Airway Registry; NEAR) provided a strict definition of FAS, while almost half (n = 10) did not provide any definition. Several (n = 3) provided a definition, but without strict criteria, stating “correct placement through the vocal cords on the first attempt” [5]. Registries without a provided predetermined definition of FAS may may experience limitations similar to retrospective chart review as documentation of FAS may be subject to an individual user's bias and personal definition. A variance in definitions between registries may also limit comparability across airway registries. Notably, Muelendyks and colleagues found a wide variety of specialties and training levels contribute to airway registries, with the most common contributors residents in emergency medicine, meaning those with the least amount of experience in airway management are often contributing to the database [5]. However, if EPs of all training levels generally have the same understanding and personal definition of FAS, limitations with retrospective chart review and some airway registry work would largely be unfounded. In that light, the primary goal of this study was to characterize the current state of agreement among EPs regarding their own personal definition and documentation of FAS in the EMR.

We conducted a cross‐sectional survey of practicing EPs, including residents, fellows, and attending physicians, distributed through academic emergency medicine channels and a national airway interest group listserv. The survey consisted of three components: (1) collection of clinical experience characteristics; (2) a free‐text question asking respondents to write their personal definition of FAS; and (3) 16 standardized emergency airway management scenarios with multiple‐choice responses indicating the number of attempts that should be documented (1, 2, 3, or ≥ 4), reflecting common electronic medical record (EMR) documentation options.

The 16 ETI scenarios were designed to isolate procedural variables that might prompt respondents to document multiple attempts rather than FAS, including laryngoscope blade insertion, ETT or introducer insertion, resuscitative interventions, and glottic visualization. The primary outcome was inter‐physician agreement on the documented number of attempts, measured using Krippendorff's alpha (α), which provides a single, chance‐corrected measure of agreement among more than two observers and is invariant to rater identity and ordering [6]. Secondary outcomes included the prevalence of predefined themes within free‐text FAS definitions. Cohen's kappa was used to determine interrater reliability between study personnel in the secondary analysis. All data were collected in Qualtrics XM, exported to Microsoft Excel, and imported into R version 4.2.2 for analysis. Clinical characteristics and scenario responses were analyzed using descriptive statistics, reporting frequencies and proportions. This study received approval from the Washington University School of Medicine Institutional Review Board.

A total of 106 EPs completed the survey. Attendings represented 64.2% of the responses (n = 68), while fellows and residents represented 5.7% (n = 6) and 30.2% (n = 32), respectively. Categorial years of experience measured in years (including residency) for respondents were: 1–5 (35%); 6–10 (33%); 11–15 (14.2%); 16–20 (4.7%); > 20 (11.3%) and missing (0.9%). Categorical number of intubations performed (estimated) were: 0–50 (18.9%); 51–100 (28.3%); 101–200 (24.5%); > 200 (25.5%); and missing (0.9%). Ten (9.4%) of respondents reported prior involvement in PCCRG Airway Trials.

Overall agreement on the documented number of attempts across scenarios was low (α = 0.13), indicating only slight agreement. Even when accounting for variables, agreement remained low across all experience levels, provider types, and prior participation in airway randomized trials (α −0.07 to 0.13; poor to slight). The results for the number of attempts broken down by each of the 16 scenarios are displayed in Figure 1.

FIGURE 1.

Scenario breakdown with intended isolate of variable permutations (reference scenario (1), blade insertions (2–5), tube/tube introducer insertions (6–10), resuscitative intervention (11–14), and glottic visualization (15–16)) thought to contribute to the decision to document a certain number of attempts for the intubation procedure note in the electronic medical record. Reported alongside the intended isolate is a percentage representative (total n = 106) who documented 1 (black) or 2 (gray) attempts. Scenarios with more disagreement have larger areas of both colors, one respondent recorded 3 attempts in one scenario (scenario 8). Overall agreement using Krippendorf's α was slight (α = 0.13). No respondents recorded that they would document more than 3 attempts in any scenario. BVM, bag‐valve mask; DL, direct laryngoscope; ETT, endotracheal tube; VL, video laryngoscope.

The secondary analysis identified themes present in respondents' written definitions of FAS. Interrater reliability between study personnel (AJL and AWR) determining the presence of predefined themes among the written definitions was excellent (Cohen's κ = 0.88; 95% CI 0.84–0.93). After adjudication (by study author CRG), 74% (78/106) of respondents mentioned laryngoscope blade insertion, 83% (88/106) mentioned ETT or endotracheal tube introducer insertion, 23% (24/106) mentioned resuscitative intervention, and 10% (11/106) mentioned glottic view. Post hoc analysis identified 14 responses containing additional themes, categorized as duration of attempt, confirmation of correct placement, intent to intubate rather than visualize, and airway trauma, present in 7% (7/106), 5% (5/106), 1% (1/106), and 1% (1/106) of responses, respectively.

This survey of primarily academic EPs found low agreement in how physicians documented the number of intubation attempts across standardized airway scenarios when not provided with a definition of FAS. There was also substantial variation in themes included when respondents were asked to define their personal definition of FAS. The greatest disagreement occurred in scenarios intended to isolate tube delivery, suggesting inconsistency in how EPs conceptualize an “attempt” even when laryngoscopy is unchanged. Overall, these findings suggest that when not provided a FAS definition, EPs use inconsistent definitions, and among EPs, their internal definition of FAS is variable and cannot be relied upon when asking if they achieved FAS.

Notably, there was unexpected variation in responses to scenarios intended to isolate similar variables. In one scenario, the proceduralist obtained a view of the glottis after a single blade insertion but removed the laryngoscope due to desaturation requiring bag‐valve‐mask ventilation before successfully intubating with one blade and one tube insertion; nearly all respondents classified this as two attempts (104/106). In a similar scenario, the blade was removed due to large‐volume emesis requiring suctioning and repositioning before successful intubation; in this case, fewer respondents (87/106) classified the procedure as two attempts. This highlights the inconsistencies observed when defining an “attempt,” even within broader categories such as resuscitative intervention.

Free‐text definitions of FAS further underscore this variability. Although blade insertion has historically defined an attempt, only 72% of respondents explicitly mentioned blade insertion in their definitions. This omission may reflect an assumption that blade insertion is implicit in intubation; however, it further supports the conclusion that consensus among personal FAS definitions is lacking.

This study has several limitations. The chain‐referral sampling method precludes calculation of a response rate and introduces potential selection bias. Most responses were obtained through academic emergency medicine channels, with limited representation from community or non‐residency‐affiliated EPs. Approximately half of respondents reported fewer than 100 lifetime intubations. While we did track for prior experience with PCCRG airway trial work, we did not collect prior airway registry work in our demographics, which would be a point of interest looking for consistency. Although scenarios were designed to isolate specific variables (e.g., blade size, blade geometry, ETT size), complete isolation was not possible, which may have resulted in overlap between scenarios. Additionally, unanticipated themes, including time, confirmation of placement, intent, and airway trauma, suggest that other factors influencing FAS definitions were not fully captured.

It is conceivable that the inconsistencies in recognition of FAS stem from historical context. FAS was initially described as an outcome of interest in the 1980s followed by the observation that failure to intubate on the first attempt was linked to adverse patient outcomes in the early 2000s [7, 8]. This association led to decades of use of FAS as both a primary research outcome and quality benchmark, with it often employed as a surrogate for patient‐centered outcomes. In reality, FAS is a description of the procedural component of ETI, which in its definition does not typically include the physiologic outcome the patient experiences. More recent literature has questioned the utility of FAS as a research endpoint, citing concerns that it may not adequately represent clinically meaningful circumstances and outcomes [9, 10]. Alternative approaches, such as the DASH‐1a initiative, emphasize not only successful airway placement but also avoidance of hypoxia [11]. DASH‐1a, while emphasizing avoidance of a physiologic adverse event, is still a composite of both a procedural (FAS) and physiologic (hypoxia) outcome, and excludes other significant physiologic outcomes such as hypotension, laryngeal trauma, or cardiac arrest.

Our findings of slight agreement in documenting intubation attempts across identical scenarios add to the growing body of literature questioning the role of FAS as a reliable outcome measure in ETI research when FAS is not strictly defined. Reliance on self‐reported data or retrospective EMR review without a provided FAS definition risks introducing significant variability and may represent a significant limitation to this type of airway research. Consistency in defining FAS could help remove this limitation and allow for more comparability across airway study groups. Further discussion is needed to determine whether a universal definition of FAS is achievable or whether more granular reporting of procedural components and physiologic outcomes represents a better path forward. When describing the procedural component of ETI, we suggest that future airway studies and registries collect detailed data on laryngoscope blade insertions, ETT and introducer insertions, resuscitative interventions, and glottic view to improve consistency, interpretability, and reproducibility of ETI research. Once consistency is maintained, future work can help to delineate which procedural components need to be added or removed from ETI research moving forward.

Disclosure

There was no use of generative AI in the creation of this manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: FAS survey.

Lacy A. J., Gerhart C. R., Safa R., et al., “How Do Emergency Physicians Define and Document First Attempt Success When No Definition Is Provided? A Survey Study,” Academic Emergency Medicine 33, no. 9 (2026): e70406, 10.1111/acem.70406.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.