Objectives: To characterize the landscape of process of care and safety outcomes for tracheal intubation across pediatric intensive care units
Background: Procedural process of care and safety outcomes of tracheal intubation across pediatric intensive care units has not been described. We hypothesize that the novel National Emergency Airway Registry for Children registry is a feasible tool to capture tracheal intubation process of care and outcomes.
Design: Prospective, descriptive.
Setting: Fifteen academic PICUs in North America.
Patients: Critically ill children requiring tracheal intubation in PICUs.
Interventions: Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubation in 15 PICUs from July 2010 to December 2011 using the National Emergency Airway Registry for Children tool with explicit site-specific compliance plans and operational definitions including adverse tracheal intubation associated events.
Measurement and Main Results: One thousand seven hundred fifteen tracheal intubation encounters were reported (averaging 1/3.4 days, or 1/86 bed days). Ninety-eight percent of primary tracheal intubation were successful; 86% were successful with less than or equal to two attempts. First attempt was by pediatric residents in 23%, pediatric critical care fellows in 41%, and critical care attending physicians in 13%: first attempt success rate was 62%, first provider success rate was 79%. The first method was oral intubation in 1,659 (98%) and nasal in 55 (2%). Direct laryngoscopy was used in 96%. Ninety percent of tracheal intubation were with cuffed tracheal tubes. Adverse tracheal intubation associated events were reported in 20% of intubations (n = 372), with severe tracheal intubation associated events in 6% (n = 115). Esophageal intubation with immediate recognition was the most common tracheal intubation associated events (n = 167, 9%). History of difficult airway, diagnostic category, unstable hemodynamics, and resident provider as first airway provider were associated with occurrence of tracheal intubation associated events. Severe tracheal intubation associated events were associated with diagnostic category and pre-existing unstable hemodynamics. Elective tracheal intubation status was associated with fewer severe tracheal intubation associated events.
Conclusions: National Emergency Airway Registry for Children was feasible to characterize PICU tracheal intubation procedural process of care and safety outcomes. Self-reported adverse tracheal intubation associated events occurred frequently and were associated with patient, provider, and practice characteristics.
1 Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, PA.
2 Center for Simulation, Advanced Education and Innovation, The Children’s Hospital of Philadelphia, PA.
3 Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Children’s Hospital, Duke University Medical Center, Durham, NC.
4 Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard University School of Medicine, Boston, MA.
* See also p. 932.
Supported, in part, by AHRQ R03HS021583-01, Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia, and Laerdal Foundation Acute Care Medicine.
Dr. Brown is teaching faculty for the Difficult Airway Course: Emergency. Dr. Walls provided expert testimony to Black, Lowe and Graham LLC and received royalties from the Cricothyrotomy Kit (manufactured book- Cook Critical Care, partner in Airway Management Center LLC). The remaining authors have not disclosed any potential conflicts of interest.
For information regarding this article, E-mail: Nishisaki@email.chop.edu