Pneumonia diagnosis performance in the emergency department: a mixed-methods study about clinicians' experiences and exploration of individual differences and response to diagnostic performance feedback.

OBJECTIVES: We sought to (1) characterize the process of diagnosing pneumonia in an emergency department (ED) and (2) examine clinician reactions to a clinician-facing diagnostic discordance feedback tool. MATERIALS AND METHODS: We designed a diagnostic feedback tool, using electronic health record data from ED clinicians' patients to establish concordance or discordance between ED diagnosis, radiology reports, and hospital discharge diagnosis for pneumonia. We conducted semistructured interviews with 11 ED clinicians about pneumonia diagnosis and reactions to the feedback tool. We administered surveys measuring individual differences in mindset beliefs, comfort with feedback, and feedback tool usability. We qualitatively analyzed interview transcripts and descriptively analyzed survey data. RESULTS: Thematic results revealed: (1) the diagnostic process for pneumonia in the ED is characterized by diagnostic uncertainty and may be secondary to goals to treat and dispose the patient; (2) clinician diagnostic self-evaluation is a fragmented, inconsistent process of case review and follow-up that a feedback tool could fill; (3) the feedback tool was described favorably, with task and normative feedback harnessing clinician values of high-quality patient care and personal excellence; and (4) strong reactions to diagnostic feedback varied from implicit trust to profound skepticism about the validity of the concordance metric. Survey results suggested a relationship between clinicians' individual differences in learning and failure beliefs, feedback experience, and usability ratings. DISCUSSION AND CONCLUSION: Clinicians value feedback on pneumonia diagnoses. Our results highlight the importance of feedback about diagnostic performance and suggest directions for considering individual differences in feedback tool design and implementation.

The Influence of COVID on Emergency Medicine Career Choice: A Survey of Medical Students.

Background The COVID-19 pandemic has led to substantial changes in the delivery of healthcare and medical education. Little is known about how the pandemic has altered medical students' perceptions in regard to career choice. Methods The authors developed and implemented a multi-center survey that evaluated medical students' preferred career choice before and during the coronavirus pandemic, as well as the influence of pandemic-related factors on that choice. The survey was distributed to all levels of medical students (MS) at nine medical schools across the country from November 2020 to January 2021 and represented a convenience sample. Preferred career choice was assessed through the use of a Likert scale and additional factors affecting career choice were solicited. The degree of interest before and during the pandemic, as well as factors influencing the shift, were treated as ordinal variables and compared using chi-squared testing. Cohen's Kappa statistic was calculated to assess the degree of shifts of interest in Emergency Medicine among students. The study was deemed exempt by the Institutional Review Board at the host institution, Sidney Kimmel Medical College at Thomas Jefferson University, and all participating sites. Results A total of 1431 of 6710 (21.3%) eligible students completed the survey. The COVID pandemic was cited as a reason for a changed interest in specialty by 193 (13.5%) students. The most common reason for specialty change was the students' clinical experience, followed by a desire to be on the front lines, and personal/family health concerns. There was a significant association between career change and degree of interest among students interested in emergency medicine (EM) as their future specialty before the COVID pandemic as well as during the COVID pandemic. Living with an immunocompromised individual had a significant association with a reduced interest in EM. There was a significant association between EM rotation completion and how interested students were in EM as their future specialty before the COVID pandemic and during the COVID pandemic. Among EM-interested students whose specialty interest was changed by the COVID pandemic, 34 (41.5%) became less favorable to EM, 28 (34.2%) stayed the same, and 20 (24.4%) students became more favorable to EM. Conclusions The impact of COVID-19 on medical students' career choice is a complicated matter that involves both personal and professional factors. It appears that there is a trend towards less interest in the field of EM with multifactorial influences, some of which are related to the COVID-19 pandemic.

Perspectives From Students and Faculty on How Women Achieve Leadership Roles in Academic Medicine: An Exploratory Qualitative Study.

INTRODUCTION: The glass ceiling in academic medicine has resulted in lower pay and fewer career advancement opportunities for women. Creating change relies on preparing early-career women for positions of leadership, but most leadership programs focus on faculty, not trainees. The present exploratory qualitative study investigates how to prepare women medical students to be leaders in academic medicine. METHODS: Focus groups with medical students and faculty who identify as women were conducted at an academic medical center in the West. A total of 25 individuals (10 students and 15 faculty) participated. Recordings of focus groups were transcribed and coded using thematic analysis until saturation of themes was achieved. FINDINGS: Codes were organized into three themes: obstacles, support systems, and self-presentation. Obstacles identified included the subthemes microaggressions, macroaggressions, a lack of female role models in leadership, and personal characteristics such as the ability to self-promote and remain resilient. Support systems included sponsorship, allyship, mentorship, networking, and gender-specific role modeling subthemes. Self-presentation involved learning behaviors for demonstrating leadership and exuding confidence, being strategic about career moves, resiliency, and navigating social norms. CONCLUSIONS: The key themes of obstacles, support systems, and self-presentation are targets for systemic and individualistic improvement in leadership development.

Differences in Emergency Medicine Resident Procedural Reporting by Gender in the United States.

Background Studies across specialties have demonstrated gender disparities in feedback, learner assessments, and operative cases. However, data are limited on differences in numbers of procedures among residents. Objective To quantify the association between gender and the number of procedures reported among emergency medicine (EM) residents. Methods We conducted a retrospective review of procedural differences by self-identified gender among graduating EM residents at 8 separate programs over a 10-year period (2013 to 2022). Sites were selected to ensure diversity of program length, program type, and geography. Residents from combined training programs, those who did not complete their full training at that institution, and those who did not have data available were excluded. We calculated the mean, SD, median, and IQR for each procedure by gender. We compared reported procedures by gender using linear regression, controlling for institution, and performed a sensitivity analysis excluding outlier residents with procedure totals >3 SD from the mean. Results We collected data from 914 residents, with 880 (96.3%) meeting inclusion criteria. There were 358 (40.7%) women and 522 (59.3%) men. The most common procedures were point-of-care ultrasound, adult medical resuscitation, adult trauma resuscitation, and intubations. After adjusting for institutions, the number of dislocation reductions, chest tube insertions, and sedations were higher for men. The sensitivity analysis findings were stable except for central lines, which were also more common in men. Conclusions In a national sample of EM programs, there were increased numbers of dislocation reductions, chest tube insertions, and sedations reported by men compared with women.

Differences in emergency medicine resident procedural reporting by race and ethnicity.

Background: The recruitment, retention, and training of physicians from groups underrepresented in medicine (UiM) is critically important to the practice of emergency medicine (EM). Studies across specialties have demonstrated disparities in operative experiences among UiM resident learners who are UiM; however, there are limited data on procedural disparities in EM. Objective: We sought to quantify the association between racial and ethnic identities that are UiM and the number of procedures reported among EM residents. Methods: We conducted a retrospective review of procedural differences by UiM status (using self-identified race and ethnicity) among graduating EM residents at nine training programs over a 10-year period. Sites were selected to ensure diversity of program length, program type, and geography. Data from residents in combined training programs, those who did not complete their full training at that institution, and those with missing data or electing not to report race/ethnicity were excluded. We calculated median and interquartile ranges for each procedure by UiM status. We conducted multivariable regression analyses accounting for UiM status, gender, and site as well as a sensitivity analysis excluding values >3 standard deviations from the mean for each procedure. Results: We collected data from 988 total residents, with 718 (73%) being non-UiM, 204 (21%) being UiM, 48 (5%) electing not to specific race/ethnicity, and 18 (2%) missing race/ethnicity data. While unadjusted data demonstrated a difference between UiM and non-UiM resident numbers across several procedures, there were no significant differences in procedures reported after accounting for gender and site in the primary or sensitivity analyses. Conclusions: We did not identify a statistically significant difference in reported procedures between UiM and non-UiM residents in EM. Future work should include qualitative investigations of UiM resident experience surrounding procedures as well as mixed-methods studies to examine how these data interact.

Virtual Shadowing: An Effective Approach to Gaining Exposure to the Field of Emergency Medicine.

Purpose: Shadowing is an important part of medical student education. The COVID-19 pandemic limited medical students' hospital access. At the same time, virtual access to learning experiences has expanded greatly. In response, we implemented a novel virtual shadowing system to provide students with convenient and safe exposure to the Emergency Department (ED). Patients and Methods: Six EM faculty hosted 2-hour virtual shadowing for up to 10 students per experience. Students registered via signupgenius.com. Virtual shadowing was conducted using a HIPAA-compliant ZOOM account on an ED issued mobile telehealth Monitor/iPad. The physician would bring the iPad into the room, obtain consent from patients, and ensure students were able to see the encounter. Between visits, students were encouraged to ask questions using the chat function and microphone. A short de-briefing followed each shift. Each participant received a survey about the experience. The survey consisted of 4 questions for demographics, 9 Likert style questions to assess efficacy, and 2 free response sections for comments and feedback. All survey responses were anonymous. Results: In total, 58 students participated in 18 virtual shadowing sessions with an average of 3-4 students per session. Survey responses were collected between October 20, 2020 and November 20, 2020. The overall response rate was 96.6% (56/58 surveys completed). Of respondents, 46 (82.1%) rated the experience as "effective" or "very effective" at providing exposure to Emergency Medicine. Fifty-three (94.6%) said they would participate in virtual shadowing in the ED again, and 48 (85.7%) would do virtual shadowing in another specialty were it available. Conclusion: We found virtual shadowing to be an easy to implement and effective way for students to shadow physicians in the ED. Even in post-pandemic times, virtual shadowing should be explored as an accessible and effective way to expose students to a broad array of specialties.

Trends in point-of-care ultrasound use among emergency medicine residency programs over a 10-year period.

Background: Point-of-care ultrasound (POCUS) is increasingly utilized in emergency medicine (EM). While residents are required by the Accreditation Council for General Medical Education to complete a minimum of 150 POCUS examinations before graduation, the distribution of examination types is not well-described. This study sought to assess the number and distribution of POCUS examinations completed during EM residency training and evaluate trends over time. Methods: This was a 10-year retrospective review of POCUS examinations across five EM residency programs. The study sites were deliberately selected to represent diversity in program type, program length, and geography. Data from EM residents graduating from 2013 to 2022 were eligible for inclusion. Exclusion criteria were residents in combined training programs, residents who did not complete all training at one institution, and residents who did not have data available. Examination types were identified from the American College of Emergency Physicians guidelines for POCUS. Each site obtained POCUS examination totals for every resident upon graduation. We calculated the mean and 95% confidence interval for each procedure across study years. Results: A total of 535 residents were eligible for inclusion, with 524 (97.9%) meeting all inclusion criteria. The mean number of POCUS examinations per resident increased by 46.9% from 277 in 2013 to 407 in 2022. All examination types had stable or increasing frequency. Focused assessment with sonography in trauma (FAST), cardiac, obstetric/gynecologic, and renal/bladder were performed most frequently. Ocular, deep venous thrombosis, musculoskeletal, skin/soft tissue, thoracic, and cardiac examinations had the largest percentage increase in numbers over the 10-year period, while bowel and testicular POCUS remained rare. Conclusions: There was an overall increase in the number of POCUS examinations performed by EM residents over the past 10 years, with FAST, cardiac, obstetric/gynecologic, and renal/bladder being the most common examination types. Among less common procedures, increased frequency may be needed to ensure competence and avoid skill decay for those examination types. This information can help inform POCUS training in residency and accreditation requirements.

Trends in emergency medicine resident procedural reporting over a 10-year period.

Background: Procedural competency is expected of all emergency medicine (EM) residents upon graduation. The ACGME requires a minimum number of essential procedures to successfully complete training. However, data are limited on the actual number of procedures residents perform and prior studies are limited to single institutions over short time periods. This study sought to assess the number of Key Index Procedures completed during EM residency training and evaluate trends over time. Methods: We conducted a retrospective review of graduating EM resident procedure logs across eight ACGME accredited residency programs over the last 10 years (2013-2022). Sites were selected to ensure diversity of program length, program type, and geography. All data from EM residents graduating in 2013-2022 were eligible for inclusion. Data from residents from combined training programs, those who did not complete their full training at that institution (i.e., transferred in/out), or those who did not have data available were excluded. We determined the list of procedures based upon the ACGME Key Index Procedures list. Sites obtained totals for each of the identified procedures for each resident upon graduation. We calculated the mean and 95% CI for each procedure. Results: We collected data from a total of 914 residents, with 881 (96.4%) meeting inclusion criteria. The most common procedures were point-of-care ultrasound, adult medical resuscitation, adult trauma resuscitation, and intubation. The least frequent procedures included pericardiocentesis, cricothyroidotomy, cardiac pacing, vaginal delivery, and chest tubes. Most procedures were stable over time with the exception of lumbar punctures (decreased) and point-of-care ultrasound (increased). Conclusions: In a national sample of EM programs, procedural numbers remained stable except for lumbar puncture and ultrasound. This information can inform residency training curricula and accreditation requirements.

Educator's blueprint: A how-to guide for developing high-quality multiple-choice questions.

Multiple-choice questions are commonly used for assessing learners' knowledge, as part of educational programs and scholarly endeavors. To ensure that questions accurately assess the learners and provide meaningful data, it is important to understand best practices in multiple-choice question design. This Educator's Blueprint paper provides 10 strategies for developing high-quality multiple-choice questions. These strategies include determining the purpose, objectives, and scope of the question; assembling a writing team; writing succinctly; asking questions that assess knowledge and comprehension rather than test-taking ability; ensuring consistent and independent answer choices; using plausible foils; avoiding grouped options; selecting the ideal response number and order; writing high-quality explanations; and gathering validity evidence before and evaluating the questions after use.

Scheduling practices for pregnant emergency medicine residents.

Background: Night shift work is associated with adverse pathophysiologic effects on maternal and fetal well-being. Although emergency medicine (EM) residents work frequent night shifts, there is no existing guidance for residency program directors (PDs) regarding scheduling pregnant residents. Our study assessed scheduling practices for pregnant EM residents, differences based on program and PD characteristics, barriers and attitudes toward implementing a formal scheduling policy, and PDs' awareness of literature describing adverse effects of night shifts on maternal-fetal outcomes. Methods: We conducted an anonymous, web-based survey of U.S. EM residencies (N = 276). Quantitative data were summarized; chi-square analysis and logistic regression were used to assess relationships between program and PD characteristics and schedule accommodations. Qualitative description was used to analyze an open-ended question, organizing findings into major and minor themes. Results: Of the 167 completed surveys (response rate 61%), 67% of programs reported no formal policy for scheduling pregnant residents but made adjustments on an individual basis including block changes (85%), decreased (46%) or no night shifts (34%), and working shifts earlier in pregnancy to cover later shifts (20%). Barriers to adjustments included staffing constraints (60%), equity concerns (45%), or impact on wellness (41%) among all residents and privacy (28%). PDs endorsed scheduling adjustments as important (mean 8.1, 0-10 scale) and reported guidance from graduate medical education governance would be useful (60%). Larger program size, but not PD gender or proportion of female residents, was associated with an increased likelihood of scheduling modifications. Twenty-five percent of PDs reported little knowledge of literature regarding night shift work and pregnancy. Qualitative themes supported quantitative findings. Conclusions: Most EM residency programs do not have formal scheduling policies for pregnant residents, but most PDs support making adjustments and do so informally. More education and guidance for PDs are needed to promote the development of formal policies.

Sources of Distress and Coping Strategies Among Emergency Physicians During COVID-19.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has been shown to increase levels of psychological distress among healthcare workers. Little is known, however, about specific positive and negative individual and organizational factors that affect the mental health of emergency physicians (EP) during COVID-19. Our objective was to assess these factors in a broad geographic sample of EPs in the United States. METHODS: We conducted an electronic, prospective, cross-sectional national survey of EPs from October 6-December 29, 2020. Measures assessed negative mental health outcomes (depression, anxiety, post-traumatic stress, and insomnia), positive work-related outcomes, and strategies used to cope with COVID-19. After preliminary analyses and internal reliability testing, we performed four separate three-stage hierarchical multiple regression analyses to examine individual and organizational predictive factors for psychological distress. RESULTS: Response rate was 50%, with 259 EPs completing the survey from 11 different sites. Overall, 85% of respondents reported negative psychological effects due to COVID-19. Participants reported feeling more stressed (31%), lonelier (26%), more anxious (25%), more irritable (24%) and sadder (17.5%). Prevalence of mental health conditions was 17% for depression, 13% for anxiety, 7.5% for post-traumatic stress disorder (PTSD), and 18% for insomnia. Regular exercise decreased from 69% to 56%, while daily alcohol use increased from 8% to 15%. Coping strategies of behavioral disengagement, self-blame, and venting were significant predictors of psychological distress, while humor and positive reframing were negatively associated with psychological distress. CONCLUSION: Emergency physicians have experienced high levels of psychological distress during the COVID-19 pandemic. Those using avoidant coping strategies were most likely to experience depression, anxiety, insomnia, and PTSD, while humor and positive reframing were effective coping strategies.

Gender-based Barriers to the Advancement of Women in Academic Emergency Medicine: A Multi-Institutional Survey Study.

INTRODUCTION: Leadership positions occupied by women within academic emergency medicine have remained stagnant despite increasing numbers of women with faculty appointments. We distributed a multi-institutional survey to women faculty and residents to evaluate categorical characteristics contributing to success and differences between the two groups. METHODS: An institutional review board-approved electronic survey was distributed to women faculty and residents at eight institutions and were completed anonymously. We created survey questions to assess multiple categories: determination; resiliency; career support and obstacles; career aspiration; and gender discrimination. Most questions used a Likert five-point scale. Responses for each question and category were averaged and deemed significant if the average was greater than or equal to 4 in the affirmative, or less than or equal to 2 in the negative. We calculated proportions for binary questions. RESULTS: The overall response rate was 55.23% (95/172). The faculty response rate was 54.1% (59/109) and residents' response rate was 57.1% (36/63). Significant levels of resiliency were reported, with a mean score of 4.02. Childbearing and rearing were not significant barriers overall but were more commonly reported as barriers for faculty over residents (P <0.001). Obstacles reported included a lack of confidence during work-related negotiations and insufficient research experience. Notably, 68.4% (65/95) of respondents experienced gender discrimination and 9.5% (9/95) reported at least one encounter of sexual assault by a colleague or supervisor during their career. CONCLUSION: Targeted interventions to promote female leadership in academic emergency medicine include coaching on negotiation skills, improved resources and mentorship to support research, and enforcement of safe work environments. Female emergency physician resiliency is high and not a barrier to career advancement.

Resource Utilization and Emergency Medicine Advisors' Approach to Video Interview Preparation.

Introduction The Standardized Video Interview (SVI) was a residency application component introduced by the Association of American Medical Colleges (AAMC) as a supplement to the existing process, which aimed to measure knowledge of professional behaviors and interpersonal skills. Given its novelty in both aim and execution, little advice or experience was available to inform preparation strategies. We sought to perform a cross-sectional analysis to explore advisors' practices in guiding students' preparation for the SVI. Methods An electronic questionnaire was developed and piloted for flow and usability, then distributed to all members of the Council of Residency Directors in Emergency Medicine (CORD EM), the professional society for emergency medicine educators, via listserv, comprised of 270 residency programs. Questions were both open- and closed-ended and therefore analyzed in a mixed-method fashion.  Results We received 56 responses from a listserv representing 270 residency programs. Respondents cited personal experience and consensus opinions from national organizations as the primary sources for their advice. The most common resources offered to students were space for completing the SVI (41%) or technical support for completing the SVI (47%). The time committed to student advising specifically for the SVI ranged from zero to 20 hours. Estimated associated costs of preparation ranged from zero up to $10,000 (time plus resources). Two individuals reported recommending commercial preparation resources to students.  Conclusion The SVI was a novel attempt to augment the resident application process. We found variability in resources and advice offered to students, including broad ranges of time dedicated, the monetary value of resources contributed, and the types of resources utilized. As the global COVID-19 pandemic has inspired a wave of innovation and process changes, we present this data for consideration as a snapshot of the variable responses to a single uniform process change.

Beyond the emergency department: Effects of COVID-19 on emergency medicine resident education.

BACKGROUND: In December 2019, a novel coronavirus (COVID-19) caused widespread clinical disease, triggering limited in-person gatherings and social-distancing guidelines to minimize transmission. These regulations led most emergency medicine (EM) residency training programs to rapidly transition to virtual didactics. We sought to evaluate EM resident perceptions of the effects of COVID-19 on their didactic and clinical education. METHODS: We performed a cross-sectional survey study at seven EM residency programs using a mixed-methods approach designed to understand resident perceptions regarding the impact of COVID-19 on their educational experience. Quantitative data were presented as percentages with comparison of subgroups, while open-ended responses were analyzed using qualitative methodology. RESULTS: We achieved a 59% response rate (187/313). The majority of respondents (119/182, 65.4%) reported that the COVID-19 pandemic had a negative impact on their residency education with junior residents disproportionately affected. A total of 81 of 182 (44.5%) participants reported that one or more of their clinical rotations were partially or completely canceled due to the pandemic. Additionally, we identified four themes and 34 subthemes highlighting the contextual effects of the pandemic, which were then divided into positive and negative influences on the residency experience. The four themes include systems experience, clinical experience, didactic experience, and wellness. CONCLUSION: Our study examined the impact of COVID-19 on residents' educational experiences. We found overall mixed responses with a slightly negative impact on residency education, wellness, and clinical rotations, while satisfaction with EM as a career choice was increased. Factors influencing this included systems, clinical, and didactic experiences as well as overall wellness.

The association of rocuronium dosing and first-attempt intubation success in adult emergency department patients.

BACKGROUND: The recommended rocuronium dose for rapid sequence intubation is 1.0 mg/kg; however, the optimal dose for emergency airway management is not clear. We assessed the relationship between rocuronium dose and first-attempt success among emergency department (ED) patients undergoing rapid sequence intubation. METHODS: This is a secondary analysis of the National Emergency Airway Registry (NEAR), an observational 25-center registry of ED intubations. Ninety percent recording compliance was required from each site for data inclusion. We included all patients > 14 years of age who received rocuronium for rapid sequence intubation from 1 Jan 2016 to 31 Dec 2018. We compared first-attempt success between encounters using alternative rocuronium doses (< 1.0, 1.0-1.1, 1.2-1.3 and ≥1.4 mg/kg). We performed logistic regressions to control for predictors of difficult airways, indication, pre-intubation hemodynamics, operator, body habitus and device. We also performed subgroup analyses stratified by device (direct vs. video laryngoscopy). We calculated univariate descriptive statistics and odds ratios (OR) from multivariable logistic regressions with cluster-adjusted 95% confidence intervals (CI). RESULTS: 19,071 encounters were recorded during the 3-year period. Of these, 8,034 utilized rocuronium for rapid sequence intubation. Overall, first attempt success was 88.4% for < 1.0 mg/kg, 88.1% for 1.0-1.1 mg/kg, 89.7% for 1.2-1.3 mg/kg, and 92.2% for ≥1.4 mg/kg. Logistic regression demonstrated that when direct laryngoscopy was used and when compared to the standard dosing range of 1.0-1.1 mg/kg, the adjusted odds of a first attempt success was significantly higher in ≥1.4 mg/kg group at 1.9 (95% CI 1.3-2.7) relative to the other dosing ranges, OR 0.9 (95% CI 0.7-1.2) for < 1.0 mg/kg and OR 1.2 (95% CI 0.9-1.7) for the 1.2-1.3 mg/kg group. First-attempt success was similar across all rocuronium doses among patients utilizing video laryngoscopy. Patients who were hypotensive (SBP < 100 mmHg) prior to intubation had higher first-attempt success 94.9% versus 88.6% when higher doses of rocuronium were used. The rates of all peri-intubation adverse events and desaturation were similar between dosing groups, laryngoscope type utilized and varying pre-intubation hemodynamics. CONCLUSIONS: Rocuronium dosed ≥1.4 mg/kg was associated with higher first attempt success when using direct laryngoscopy and among patients with pre-intubation hypotension with no increase in adverse events. We recommend further prospective evaluation of the dosing of rocuronium prior to offering definitive clinical guidance.

RéSUMé: CONTEXTE: La dose de rocuronium recommandée pour l'intubation à séquence rapide est de 1,0 mg / kg, mais la dose optimale pour la prise en charge des voies respiratoires d'urgence n'est pas claire. Nous avons évalué la relation entre la dose de rocuronium et la réussite de la première tentative chez les patients des services d'urgence soumis à une intubation à séquence rapide. MéTHODES : Il s'agit d'une analyse secondaire du National Emergency Airway Registry (NEAR), un registre d'observation des intubations aux urgences dans 25 centres. Pour que les données soient prises en compte, chaque site devait respecter 90 % des enregistrements. Nous avons inclus tous les patients âgés de plus de 14 ans qui ont reçu du rocuronium pour une intubation à séquence rapide du 1er janvier 2016 au 31 décembre 2018. Nous avons comparé le succès de la première tentative entre les rencontres utilisant des doses alternatives de rocuronium (<1,0 mg/kg, 1,0-1,1 mg/kg, 1,2-1,3 mg/kg et 1,4mg/kg). Nous avons effectué des régressions logistiques pour contrôler les facteurs prédictifs des voies aériennes difficiles, l'indication, l'hémodynamique pré-intubation, l'opérateur, l'habitus corporel et le dispositif. Nous avons également effectué des analyses de sous-groupes stratifiées par dispositif (laryngoscopie directe contre vidéo-laryngoscopie). Nous avons calculé des statistiques descriptives univariées et des rapports des cotes (RC) à partir de régressions logistiques multivariables avec des intervalles de confiance (IC) à 95 % ajustés par groupe RéSULTATS: 19 071 consultations ont été enregistrées au cours de la période de trois ans. Parmi celles-ci, 8 034 ont utilisé du rocuronium pour une intubation à séquence rapide. Dans l'ensemble, le succès de la première tentative était de 88,4 % pour <1,0 mg/kg, 88,1 % pour 1,0 à 1,1 mg/kg, 89,7 % pour 1,2 à 1,3 mg/kg et 92,2 % pour ≥1,4 mg/kg. La régression logistique a démontré que lorsque la laryngoscopie directe était utilisée et comparée à la gamme de dosage standard de 1,0-1,1 mg/kg, la probabilité ajustée de réussite de la première tentative était significativement plus élevée dans le groupe ≥ 1,4mg/kg à 1,9 (IC 95 % 1,3-2,7) par rapport aux autres gammes de dosage, RC 0,9 (IC 95 % 0,7-1,2) pour < 1,0 mg/kg et RC 1,2 (IC 95 % 0,9-1,7) pour le groupe 1,2-1,3 mg/kg. La réussite de la première tentative était similaire pour toutes les doses de rocuronium chez les patients utilisant la vidéo-laryngoscopie. Les patients qui étaient hypotendus (SBP <100 mmHg) avant l'intubation avaient un taux de réussite de la première tentative plus élevé 94,9% contre 88,6% lorsque des doses plus élevées de rocuronium étaient utilisées. Les taux de tous les effets indésirables péri-intubation et de désaturation étaient similaires entre les groupes de dosage, le type de laryngoscope utilisé et les différentes hémodynamiques pré-intubation CONCLUSIONS: Le rocuronium dosé à ≥1,4mg/kg a été associé à une meilleure réussite de la première tentative lors de l'utilisation de la laryngoscopie directe et chez les patients présentant une hypotension avant intubation, sans augmentation des effets indésirables. Nous recommandons une évaluation prospective plus poussée du dosage du rocuronium avant de proposer une orientation clinique définitive.