Quality and Safety

Promoters and Barriers to Implementation of Tracheal Intubation Airway Safety Bundle: A Mixed-Method Analysis*

Finn Davis, Katherine PhD, APRN, CPNP¹; Napolitano, Natalie MPH, RRT-NPS, FAARC²; Li, Simon MD, MPH^3,4; Buffman, Hayley MPH⁵; Rehder, Kyle MD⁶; Pinto, Matthew MD³; Nett, Sholeen MD, PhD⁷; Jarvis, J. Dean RN, MBA⁷; Kamat, Pradip MD, MBA⁸; Sanders, Ronald C. Jr MD, MS⁹; Turner, David A. MD, FCCN, FCCP⁶; Sullivan, Janice E. MD¹⁰; Bysani, Kris MD¹¹; Lee, Anthony MD¹²; Parker, Margaret MD, MCCM¹³; Adu-Darko, Michelle MD, FAAP¹⁴; Giuliano, John Jr MD¹⁵; Biagas, Katherine MD, FCCM, FAAP¹⁶; Nadkarni, Vinay MD, MS^5,17; Nishisaki, Akira MD, MSCE^5,17

Author Information

¹University of Hawai’i at Mānoa, School of Nursing and Dental Hygiene, Honolulu, HI.

²Department of Respiratory Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA.

³Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children’s Hospital, Valhalla, NY.

⁴Department of Pediatrics, New York Medical College, Valhalla, NY.

⁵Center for Simulation, Advanced Education and Innovation, Children’s Hospital of Philadelphia, Philadelphia, PA.

⁶Department of Pediatrics, Division of Critical Care, Duke Children’s Hospital, Durham, NC.

⁷Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

⁸Department of Pediatrics, Emory University School of Medicine, Children’s Hospital of Atlanta, Atlanta, GA.

⁹Department of Pediatrics, Section of Pediatric Critical Care, UAMS/Arkansas Children’s Hospital, Little Rock, AR.

¹⁰Department of Pediatrics, Division of Critical Care, University of Louisville and Norton Children’s Hospital, Louisville, KY.

¹¹Pediatric Critical Care Medicine, Medical City Children's Hospital, Dallas, TX.

¹²Nationwide Children’s Hospital, Columbus, OH.

¹³Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children’s Hospital, Stony Brook, NY.

¹⁴Pediatric Critical Care Medicine, The University of Virginia Health System Children's Hospital, Charlottesville, VA.

¹⁵Yale Pediatric Critical Care Medicine, Yale-New Haven Children’s Hospital, New Haven, CT.

¹⁶Department of Pediatrics, Columbia University Medical Center, New York, NY.

¹⁷Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA.

*See also p. 994.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by Agency for Healthcare Research and Quality (AHRQ): AHRQ R03HS021583, R18 HS022464, and R18HS024511 and Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia.

Dr. Davis’ former institution received funding from Agency for Healthcare Research and Quality (AHRQ) (AHRQ R03HS021583, AHRQ R18HS022464, and AHRQ 1R18HS024511-01). Dr. Napolitano received funding from board membership for Allergy and Asthma Network and American Association for Respiratory Care; she received support for article research from AHRQ R18 grant; her institution received funding from AHRQ R18 (National Emergency Airway Registry—airway bundle development and qualitative analysis), CVS Health (development of tobacco dependence program), consulting work for product development for Actuated Medical and GeNO, and from research funding and speaking fees from Draeger Medical and Aerogen. Dr. Buffman received funding from AHRQ R18HS022464 grant, as a research coordinator for this project. Dr. Sullivan received support for article research from the National Institutes of Health. Dr. Parker received funding from Raynes McCarty. Dr. Nishisaki’s institution received funding from AHRQ R03HS021583, AHRQ R18HS022464, and AHRQ 1R18HS024511-01. The remaining authors have disclosed that they do not have any potential conflicts of interest.

This work was completed at Department of Nursing, Children’s Hospital of Philadelphia, Philadelphia, PA.

For information regarding this article, E-mail: [email protected]

Pediatric Critical Care Medicine 18(10):p 965-972, October 2017. | DOI: 10.1097/PCC.0000000000001251

Abstract

Objectives:

To describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders.

Design:

Mixed methods.

Setting:

Thirteen PICUs of the National Emergency Airway Registry for Children network.

Intervention:

Remote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks.

Measurements and Main Results:

Bundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182–781). Five sites were early (median, 153 d; interquartile range, 146–267) and eight sites were late adopters (median, 783 d; interquartile range, 773–845). Focus groups identified common “promoter” themes—interdisciplinary approach, influential champions, and quality improvement bundle customization—and “barrier” themes—time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention.

Conclusions:

Implementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

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Promoters and Barriers to Implementation of Tracheal Intubation Airway Safety Bundle: A Mixed-Method Analysis*