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Practical strategies EMS agencies can implement now to improve airway performance, reduce skill decay, and support consistent intubation success in the field.
Abstract
Paramedics and other credentialed providers must perform endotracheal intubation (ETI) safely and effectively. Yet ETI remains a high-risk, low-frequency procedure in prehospital emergency care. Many paramedics perform few, if any, live intubations each year, creating challenges for maintaining proficiency, confidence, and decision-making under pressure.
As supraglottic airway use increases and clinical exposure declines, emergency medical services (EMS) leadership and medical directors face an important question: How can airway competency be sustained over time? This article examines the system-level factors that contribute to airway skill decay and inconsistent performance.
More importantly, it provides practical strategies that EMS agencies can implement immediately to strengthen airway competency through continuous training, clinical exposure, structured feedback, performance tracking, and leadership support. Competent airway performance is not achieved through certification alone. It requires a deliberate system designed to maintain readiness every day.
Problem:
Paramedic endotracheal intubation (ETI) remains a high-risk, low-frequency skill with inconsistent success, driven by skill decay and limited clinical exposure.
What This Article Adds:
This article translates current evidence and qualitative findings into practical, system-level strategies to sustain airway competency in real-world EMS settings.
Key Insights:
ETI performance gaps stem from three issues: insufficient ongoing training, limited access to live intubations, and inconsistent feedback systems.
Simulation improves confidence and maintains procedural technique but does not sustain performance without repeated practice, real-world exposure, and structured debriefing. Organizational culture and leadership directly influence outcomes.
Bottom Line:
Improving ETI performance requires more than training. EMS systems must redesign how airway competency is developed, reinforced, and measured to improve provider performance and patient outcomes.
Introduction
Paramedics are expected to perform a procedure with no margin for error in emergency care, yet many rarely encounter enough real-world opportunities to maintain proficiency in ETI. This gap between expectation and experience has become a persistent challenge across EMS systems, where ETI remains a high-risk, low-frequency skill with widely variable success rates. When airway management fails, the consequences are immediate and significant, directly impacting patient outcomes in cardiac arrest, respiratory failure, and trauma.1
Despite decades of emphasis on airway training, the problem has not been solved. Many agencies continue to rely on initial certification and periodic refresher training as the primary mechanisms for maintaining competency. While simulation-based education and advancements such as video laryngoscopy have improved certain aspects of airway management, they have not eliminated the underlying issue: paramedics often do not perform enough intubations on real patients to sustain skill proficiency over time.
As a result, even well-trained providers may experience skill decay, reduced confidence, and increased reliance on alternative airway strategies.2 What is becoming increasingly clear is that inconsistent ETI performance is not simply an individual provider issue. It is a system design problem. Training, clinical exposure, quality assurance, and leadership practices are often disconnected, creating fragmented approaches that fail to reinforce long-term competency.
Without a coordinated system that supports repeated practice, real-time feedback, and ongoing performance monitoring, airway proficiency becomes difficult to sustain.3 This article shifts the focus from individual performance to system-level solutions. Drawing from current evidence and practitioner-informed insights, it outlines practical strategies EMS agencies can implement to strengthen airway competency.
Specifically, this article examines four critical areas for improvement: high-frequency training, access to live intubation opportunities, structured feedback and quality assurance systems, and leadership practices that support continuous learning. The goal is simple: to move beyond one-time training events and toward a system that consistently prepares paramedics to perform when it matters most.
The Problem (Why This Matters Now)
Paramedics know the reality. You can go weeks or months without performing an intubation, then suddenly be expected to execute it flawlessly in a high-stakes situation. This is the nature of ETI in EMS, a critical skill that is used infrequently but carries no margin for error.
Over time, that lack of exposure takes a toll. Skills that were once sharp begin to fade, confidence drops, and decision-making becomes more difficult under pressure. Even experienced providers recognize the difference between practicing a skill in training and performing it on a real patient in a chaotic, time-sensitive environment.4 This creates a frustrating disconnect.
Paramedics are trained, certified, and authorized to perform ETI, but many do not have consistent opportunities to maintain proficiency. Simulation helps, but it does not fully replicate the stress, variability, and complexity of real-world airway management.5 The result is a system that expects high performance without consistently supporting it. And when performance varies, it is often attributed to the individual provider rather than the system that shaped their training, exposure, and ongoing development.
Where Systems Break Down
The challenge with ETI in EMS is usually not a lack of training. It is how that training is structured and reinforced over time. Many systems still rely heavily on initial education and periodic refreshers. Paramedics complete airway training, demonstrate competency, and are cleared to perform intubation in the field. But after that point, ongoing procedural maintenance and refinement are often inconsistent, if not nonexistent.
There is rarely a structured pathway that ensures skills are continuously practiced, evaluated, and reinforced. Clinical exposure is another major gap. In many systems, opportunities to perform live intubations are limited. The increased use of supraglottic airways, while clinically appropriate in many situations, has further reduced exposure to ETI.
As a result, paramedics may go extended periods without performing the procedure, making it difficult to maintain both technical skill and decision-making confidence.6 Simulation has helped, but it is often used in isolation. When simulation is treated as a standalone training event rather than part of a continuous system, its impact is limited. Practicing on a mannequin in a controlled environment is fundamentally different from managing an airway in a cramped space, under time pressure, with a deteriorating patient.
Without frequent, realistic practice that mirrors field conditions, skills do not fully translate.7 Feedback systems also tend to be inconsistent. In some agencies, airway cases are reviewed regularly with structured debriefing and clear performance expectations. In others, feedback is delayed, minimal, or absent altogether. Without timely, constructive input, providers have little opportunity to refine their technique or learn from difficult cases.3
Finally, leadership, organizational culture, and medical director involvement play a bigger role than many realize. In systems where airway management is actively prioritized, supported, and openly discussed, performance tends to improve. In systems where it is treated as just another skill on a checklist, it becomes easy for competency to drift over time.8 Together, these gaps create a fragmented approach to airway management. Training, clinical experience, and performance evaluation operate in silos, rather than as parts of a coordinated system. Until those pieces are aligned, variability in ETI performance will continue.
What the Research Shows
When you step back and look across EMS systems, the pattern is consistent. Paramedics are not struggling with airway management because they were never trained. They are struggling because the system does not consistently support skill retention after training is complete.9
One of the clearest findings is that ETI proficiency declines without regular use. Providers who perform intubations more frequently tend to have higher success rates and greater confidence. Those who go long periods without performing the procedure are more likely to experience difficulty when it matters most.10
Another key insight is that simulation alone is not enough. While it improves confidence and reinforces technique, it does not fully prepare providers for real-world conditions unless it is repeated frequently and paired with actual patient experience. The gap between training and field performance remains significant when simulation is used as a standalone solution.11
The research also highlights the importance of feedback. Systems that provide consistent case review, timely debriefing, and clear performance expectations tend to produce better airway outcomes. Providers improve when they know how they performed and what to adjust the next time.12
Finally, one of the most important findings is this: airway performance is shaped as much by the system as it is by the individual. When training, exposure, and feedback are aligned, performance improves. When they are not, variability becomes the norm.13
While procedural success is an important measure of airway competency, EMS agencies should also evaluate patient-centered outcomes whenever possible. First-pass success alone does not fully capture airway performance.
Quality assurance programs should consider first-pass success without complications, unrecognized airway difficulties, hypoxia, aspiration, esophageal intubation, airway trauma, and other clinically relevant outcomes. Monitoring these measures helps agencies understand not only whether intubation was successful, but whether it was performed safely and effectively.
What Needs to Change
Improving ETI performance in EMS does not require a single breakthrough. It requires a shift in how systems approach training, exposure, and performance support. The focus must move from one-time competency to continuous development.
1. Make Airway Training Continuous, Not Occasional
Airway management cannot be treated as a skill that is learned once and revisited occasionally. Agencies should build airway training into regular operations, not just scheduled education days. Short, high-frequency training sessions, even a few minutes per shift, help maintain muscle memory and decision-making under pressure. The goal is consistent exposure, not periodic retraining.14
2. Increase Access to Real-World Intubation Opportunities
There is no substitute for live patient experience. EMS systems should actively pursue partnerships with hospitals and anesthesia teams to expand access to operating room rotations or clinical airway opportunities. Without regular real-world exposure, even well-trained providers will experience skill decline.10
3. Treat Simulation as Part of a System, Not the Solution
Simulation works best when it is frequent, realistic, and directly connected to field performance. Training scenarios should reflect real conditions such as limited space, time pressure, distractions, and deteriorating patients. Simulation should also be tied to recent cases, allowing providers to practice scenarios they are likely to encounter.15
4. Build Strong, Non-Punitive Feedback Systems
Providers improve when they receive timely, specific feedback. Agencies should implement structured airway review processes that include case debriefings, performance tracking, and clear expectations. Feedback should focus on learning, not punishment. When providers feel supported, they are more likely to engage and improve.3 Airway review processes should incorporate both procedural metrics and patient outcome measures when available.
5. Align Leadership with Airway Performance Goals
Leadership sets the tone. When airway management is treated as a priority, supported with time, resources, and attention, performance improves. Leaders should actively support training initiatives, participate in review processes, and reinforce expectations around competency. A strong culture of learning and accountability makes a measurable difference.8
What This Means for EMS Leaders
Improving airway performance is not just a training issue. It is a leadership responsibility. Leaders set the conditions under which paramedics develop and maintain critical skills. If airway competency is expected, it must be actively supported through time, structure, and resources.
This means moving beyond compliance-based training models and building systems that reinforce performance every day. First, leaders must prioritize consistency. Airway training should not compete with other operational demands. It should be built into the routine of the organization. Whether through short, shift-based drills or scheduled skill reinforcement, consistency is what prevents skill decay. Second, leaders must ensure access.
If paramedics are expected to perform ETI, they need opportunities to practice it in real clinical environments. Establishing partnerships with hospitals, anesthesia teams, or human cadaver labs is not optional. It is essential for maintaining competency.
Third, leaders must create feedback-driven systems. Performance improves when it is measured, reviewed, and discussed. Structured airway reviews, timely debriefings, and clear expectations help providers understand where they stand and how to improve. Without this, performance gaps remain hidden.
Finally, leaders must shape culture. A system that supports learning, encourages questions, and treats mistakes as opportunities for improvement will produce better outcomes than one focused solely on compliance.
When airway management is visibly prioritized by leadership, providers respond accordingly. The bottom line is simple. If EMS leaders want consistent airway performance, they must design systems that make consistency possible.
TRAINING
▲
│
│
LEADERSHIP ◄─────┼─────► EXPOSURE
SUPPORT
│
▼
PERFORMANCE TRACKING
▲
│
▼
FEEDBACK
Figure 1. The Airway Competency Cycle. Effective airway competency is maintained through a continuous cycle of training, clinical exposure, performance feedback, outcome tracking, and leadership support. Weakness in any component of the cycle can contribute to skill decay and inconsistent endotracheal intubation performance.
Implementation Framework: How to Start Monday Morning
Improving airway competency does not require a complete system overhaul on day one. It starts with small, deliberate steps that build into a structured approach over time.
Step 1: Start With a Daily Airway Touchpoint
Begin by integrating brief airway training into the daily routine. This can be as simple as a 5–10 minute drill at the start of a shift. Focus on fundamentals such as equipment setup, positioning, and decision-making. The goal is consistency, not complexity.
Step 2: Standardize Equipment and Setup
Ensure that airway equipment is organized and consistent across units. Standardization reduces cognitive load and allows providers to focus on patient care rather than searching for tools. Use the same layout, same checks, same checklists, and same expectations every shift.
Step 3: Review Every Airway Case
Implement a simple, non-punitive review process for every airway attempt. This does not need to be formal at first. A short discussion after the call or during shift change can identify what went well and what could improve. Over time, this can evolve into a structured QA process.
Step 4: Track Exposure and Performance
Start tracking how often paramedics are performing intubations and how they are performing. Even a basic spreadsheet can provide valuable insight. Identify providers who need more exposure or support and create targeted opportunities for skill development.
Step 5: Build Clinical Partnerships
Reach out to local hospitals to explore opportunities for operating room (OR) rotations or supervised airway practice. Start small. Even limited access can make a significant difference in maintaining proficiency.
Scaling the Model
Once the foundation is in place, agencies can expand into a more structured system:
1. Tier 1: Daily Reinforcement
Short, high-frequency training integrated into operations
2. Tier 2: Structured Feedback
Formal airway reviews, performance tracking, and defined benchmarks
3. Tier 3: Advanced Development
Regular simulation, OR rotations, and targeted remediation for skill gaps
Key Takeaways
- ETI is a high-risk, low-frequency skill, and without regular use, skill decay is inevitable.
- Inconsistent airway performance is a system problem, not just an individual provider issue.
- Initial training is not enough. Competency must be reinforced continuously through real-world exposure and frequent practice.
- Simulation alone does not sustain proficiency unless it is repeated often and paired with realistic scenarios and live patient experience.
- Providers perform better when they perform more. Increased intubation exposure is directly tied to improved success and confidence.
- Short, high-frequency training works. Even brief daily or shift-based airway drills can significantly improve retention and readiness.
- Feedback drives improvement. Timely, structured, non-punitive debriefing helps providers refine performance and build confidence.
- Leadership matters. Agencies that prioritize airway management through culture, resources, and accountability see better outcomes.
- Standardization reduces errors. Consistent equipment setup and processes lower cognitive load during high-stress situations.
- Start small and build momentum. You don’t need a full system overhaul. Daily training, simple case reviews, and basic tracking can begin immediately.
If we expect paramedics to perform at a high level, we must build systems that make high-level performance possible.
Conclusion
Endotracheal intubation remains one of the most important and most challenging procedures in EMS, yet the way it is supported in many systems has not kept pace with the realities of modern practice. Paramedics are asked to perform a high-risk, low-frequency skill in unpredictable environments, often without the consistent reinforcement needed to sustain proficiency.
The solution is not more isolated training. It is better system design. Agencies that improve airway performance do so by aligning training, clinical exposure, feedback, and leadership into a continuous process. They move away from one-time competency and toward ongoing development.
They create environments where skills are practiced regularly, performance is reviewed consistently, and providers are supported in improving over time.2, 3 This shift does not require a complete overhaul. It starts with small, deliberate changes, daily training touchpoints, simple case reviews, and a commitment to making airway management a visible priority.
From there, systems can build toward more structured programs that sustain competency across the workforce. The expectation for high performance in airway management is not going away. The question is whether EMS systems are designed to support it. Because in the end, consistent airway performance is not about asking more from providers. It is about building systems that make it possible.
Disclaimer
The author is the founder and president of Sentinel Skills Systems, Inc., an organization focused on EMS training and competency maintenance. No Sentinel products or services are discussed or promoted in this article.
AI Disclosure
I used CoPilot, ChatGPT, and Google AI to assist with grammar, spelling, formatting, and readability.
References
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Dr. Ronald Rivers, DM, MBA, is a retired paramedic and the founder of Sentinel Skills Systems, Inc. located in the San Francisco Bay Area. He recently completed doctoral research at the University of Phoenix examining organizational, training, and operational factors affecting paramedic endotracheal intubation performance. His work focuses on airway competency, skill retention, simulation-based training, and EMS performance improvement.
