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%.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Healthcare Patient Safety and Quality Improvement Research (HSQR)
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Gray, Darryl T
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Children's Hospital of Philadelphia
United States
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Langhan, Melissa L; Emerson, Beth L; Nett, Sholeen et al. (2018) End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry. Pediatr Crit Care Med 19:98-105
Kojima, Taiki; Laverriere, Elizabeth K; Owen, Erin B et al. (2018) Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children. Pediatr Crit Care Med 19:106-114
Li, Simon; Hsieh, Ting-Chang; Rehder, Kyle J et al. (2018) Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs. Pediatr Crit Care Med 19:e41-e50
Pouppirt, Nicole R; Nassar, Rula; Napolitano, Natalie et al. (2018) Association Between Video Laryngoscopy and Adverse Tracheal Intubation-Associated Events in the Neonatal Intensive Care Unit. J Pediatr 201:281-284.e1
Gradidge, Eleanor A; Bakar, Adnan; Tellez, David et al. (2018) Effect of Location on Tracheal Intubation Safety in Cardiac Disease-Are Cardiac ICUs Safer? Pediatr Crit Care Med 19:218-227
Gradidge, Eleanor A; Bakar, Adnan; Tellez, David et al. (2018) Safety of tracheal intubation in the presence of cardiac disease in paediatric ICUs. Cardiol Young 28:928-937
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Kojima, Taiki; Harwayne-Gidansky, Ilana; Shenoi, Asha N et al. (2018) Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children. Pediatr Crit Care Med 19:528-537
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