Tracheal intubation (TI) is a commonly performed life-saving procedure for critically ill children, but associated with frequent complications and adverse safety outcomes. With prior AHRQ and Pediatric Acute Lung Injury and Sepsis Investigator (PALISI) network support, we conducted a robust risk assessment using our multi-center pediatric TI safety registry: National Emergency Airway Registry for Children (NEAR4KIDS). We implemented a first generation TI quality improvement QI bundle including: 1) a TI risk factor checklist, 2) a bedside time-out immediately before TI, 3) a bedside time-out immediately after TI to debrief, and 4) quantitative debriefing among participating centers to share best practices. The evaluation of the clinical impact of this QI bundled intervention is ongoing with promising preliminary results (adverse TI associated event rate dropped from 19% to 16% across all NEAR4KIDS sites). However, with this QI implementation process, we have identified two precursor events: hypoxemia and multiple TI attempts, which need to be addressed to further improve TI safety. In this project, we will implement two easily adoptable interventions: apneic oxygenation (administration of oxygen throughout TI procedure via nasal cannula) and primary use of video laryngoscopes to reduce adverse TI associated events by minimizing hypoxemia and multiple attempts. This project will rigorously evaluate the clinical impact of this second generation QI intervention across a diverse spectrum of (large and small, academic and private) pediatric ICUs. Further, this project will identify and mitigate new QI practice uptake, adoption, implementation processes and variances at the site level. This approach includes standardized outcome measures using our NEAR4KIDS registry, measures of new QI practice uptake, a novel cumulative sum (CUSUM) analysis to track each site's performance prospectively, focus groups with sharp end multidisciplinary providers, and semi-structured interviews with site QI leaders. We will employ mixed- method quantitative and qualitative analyses to identify the key factors and barriers for this second generation bundled QI intervention adoption. Based on these analyses, we will further refine the QI implementation approach. The clinical impact of the implementation of apneic oxygenation and primary use of video laryngoscope will be measured prospectively by our NEAR4KIDS registry process of care measures, and most importantly by a meaningful absolute risk reduction in adverse TI associated events. Our NEAR4KIDS network has grown from 16 sites to 28 sites over last 2 years. At the completion of the this project, we have access to large implementation networks including PALISI and the American Heart Association life support training programs, who are poised to disseminate the findings beyond these 28 centers. Upon successful completion, we will understand the feasibility, barriers, and clinical impact of apneic oxygenation and video laryngoscopy on high-risk, but life-saving, TI procedural safety outcomes.

Public Health Relevance

Rescuing children from their most common cause of death (respiratory failure) by placing a tube in the airway is a common, high risk procedure with frequent complications. With prior AHRQ support, we have already created a robust and diverse national quality improvement research network of 28 pediatric ICUs, conducted a risk assessment, identified the preventable risk factors, developed and implemented simple safety interventions. We will implement our new safety intervention with continuous oxygen delivery through the procedure and with primary use of the video-assisted device to reduce potentially life-threatening complication rate by 20%.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Research Demonstration and Dissemination Projects (R18)
Project #
5R18HS024511-02
Application #
9258411
Study Section
Healthcare Patient Safety and Quality Improvement Research (HSQR)
Program Officer
Gray, Darryl T
Project Start
2016-04-08
Project End
2020-01-31
Budget Start
2017-02-01
Budget End
2018-01-31
Support Year
2
Fiscal Year
2017
Total Cost
Indirect Cost
Name
Children's Hospital of Philadelphia
Department
Type
DUNS #
073757627
City
Philadelphia
State
PA
Country
United States
Zip Code
19104
Finn Davis, Katherine; Napolitano, Natalie; Li, Simon et al. (2017) Promoters and Barriers to Implementation of Tracheal Intubation Airway Safety Bundle: A Mixed-Method Analysis. Pediatr Crit Care Med 18:965-972