Prognosis After Emergency Intubation Using a Large Dataset to Inform Decision Making

Emergency department (ED) intubation is a critical life-sustaining intervention, but may confer limited clinical benefit in some situations. However, prognostic information to guide shared decision-making remains limited. Our objective was to utilize a large electronic health record consortium to assess age-stratified mortality rates to better inform goals-of-care discussions in the ED.

We conducted a retrospective cohort study of all adult patients emergently intubated within the first full calendar day of ED arrival from January 2006 to December 2025 in Epic Cosmos, a dataset of 300m patient encounters across 1,883 hospitals. The primary independent variable was age, stratified into cohorts. The primary outcome was in-hospital mortality. We calculated age-specific adjusted odds ratios (aOR) controlling for sex, race, trauma activation, and clinical instability, defined as unresponsiveness within one hour of arrival. The secondary outcome was discharge to hospice among survivors.

We identified 2,239,290 patients who underwent emergent intubation. Overall in-hospital mortality was 32.4% (95%CI 32.3-32.4%). Mortality increased with age (Omnibus p < 0.001). Mortality rates were 18.4% (18.2-18.5%) for age 18–39, 25.5% (25.3-25.6%) for age 40-54, 30.0% (29.9-30.2%) for age 55-64, 35.6% (35.5-35.7%) for age 65-74, 41.7% (41.5-41.9%) for age 75-79, 46.5% (46.3-46.8%) for age 80-84, 50.5% (50.2-50.8%) for age 85-89, and 57.4% (57.0-57.7%) for age 90+. After adjustment, the odds of mortality increased progressively with age, reaching an aOR of 6.2 (95% CI 6.1–6.3) for those aged 90+. Clinical instability was also independently associated with in-hospital mortality with an aOR of 5.9 (5.8-5.9). The percentage of survivors discharged on hospice was 5.8% overall (95%CI 5.8-5.8%) and also varied by age: 0.6% (0.6-0.7%) for age 18-39 compared to 16.6% (16.3-17.0%) for age 85-89 and 20.3% (19.8-20.8%) for age 90+.

In this large-scale analysis, mortality following emergent intubation increased with age. More than 1 in 2 patients age 85 or older do not survive to discharge, and among survivors, nearly 1 in 5 are discharged to hospice. These findings provide clinicians with evidence to inform the decision to intubate in the ED to better align interventions with patient goals, values, and prognostic realities.