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Site-Level Variance for Adverse Tracheal Intubation–Associated Events Across 15 North American PICUs: A Report From the National Emergency Airway Registry for Children*

Nett, Sholeen MD, PhD1; Emeriaud, Guillaume MD, PhD2; Jarvis, J. Dean MBA, BSN3; Montgomery, Vicki MD4; Nadkarni, Vinay M. MD, MS5; Nishisaki, Akira MD, MSCE5

Pediatric Critical Care Medicine: May 2014 - Volume 15 - Issue 4 - p 306–313
doi: 10.1097/PCC.0000000000000120
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Objective: Tracheal intubation in PICUs is associated with adverse tracheal intubation–associated events. Patient, provider, and practice factors have been associated with tracheal intubation–associated events; however, site-level variance and the association of site-level characteristics on tracheal intubation–associated event outcomes are unknown. We hypothesize that site-level variance exists in the prevalence of tracheal intubation–associated events and that site characteristics may affect outcomes.

Design: Prospective observational cohort study.

Setting: Fifteen PICUs in North America.

Subjects: Critically ill pediatric patients requiring tracheal intubation.

Interventions: None.

Measurement and Main Results: Tracheal intubation quality improvement data were collected in 15 PICUs from July 2010 to December 2011 using a National Emergency Airway Registry for Children with robust site-specific compliance. Tracheal intubation–associated events and severe tracheal intubation–associated events were explicitly defined a priori. We analyzed the association of site-level variance with tracheal intubation–associated events using univariate analysis and adjusted for previously identified patient- and provider-level risk factors. Analysis of 1,720 consecutive intubations revealed an overall prevalence of 20% tracheal intubation–associated events and 6.5% severe tracheal intubation–associated events, with considerable site variability ranging from 0% to 44% tracheal intubation–associated events and from 0% to 20% severe tracheal intubation–associated events. Larger PICU size (> 26 beds) was associated with fewer tracheal intubation–associated events (18% vs 23%, p = 0.006), but the presence of a fellowship program was not (20% vs 18%, p = 0.58). After adjusting for patient and provider characteristics, both PICU size and fellowship presence were not associated with tracheal intubation–associated events (p = 0.44 and p = 0.18, respectively). Presence of mixed ICU with cardiac surgery was independently associated with a higher prevalence of tracheal intubation–associated events (25% vs 15%; p < 0.001; adjusted odds ratio, 1.81; 95% CI, 1.29–2.53; p = 0.01). Substantial site-level variance was observed in medication use, which was not explained by patient characteristic differences.

Conclusions: Substantial site-level variance exists in tracheal intubation practice, tracheal intubation–associated events, and severe tracheal intubation–associated events. Neither PICU size nor fellowship training program explained site-level variance. Interventions to reduce tracheal intubation–associated event prevalence and severity will likely need to be contextualized to variability in individual ICUs patients, providers, and practice.

1Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

2Department of Pediatrics, Sainte Justine Hospital, Montreal, QC, Canada.

3Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

4Department of Pediatrics, Division of Critical Care, Kosair Children’s Hospital, University of Louisville, Louisville, KY.

5Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA.

* See also p. 369.

Dr. Emeriaud was supported by Young Investigator Award of the Respiratory Health Network of the Fonds de la Recherche du Québec–Santé. Drs. Nadkarni and Nishisaki were supported by Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia, and Unrestricted Research Fund from Laerdal Foundation Acute Care Medicine. Dr. Nishisaki (principal investigator) was supported by AHRQ 1R03HS021583-01 and received support for article research from AHRQ. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies