Adolescent/Child Health

Two different tools help measure tracheal intubation adverse events and performance in pediatric intensive care units

Tracheal intubation in pediatric intensive care units (ICUs) is often performed on critically ill children in emergency situations. While this procedure can be life-saving, it can also result in adverse events ranging from esophageal intubation or a drop in blood pressure to—worst case—cardiac arrest. Preventing these events requires ways to characterize and improve care and safety outcomes. Two recent studies describe tools that can be used to accomplish these goals. The first study adapted the National Emergency Airway Registry to identify unwanted intubation-associated events. The second study used an assessment tool to rate the technical and behavioral performance of airway management teams during real intubation events. Both studies, supported in part by the Agency for Healthcare Research and Quality (HS16678), are summarized here.

Nishisaki, A., Ferry S., Colborn S., and others (2012). "Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit." Pediatric Critical Care Medicine 13(1), pp. e5-e10.

The National Emergency Airway Registry was established in 1996 as a multicenter emergency department advanced airway management registry. Researchers modified the data elements so that the registry could characterize the process of care and safety outcomes for critically ill children in a 45-bed tertiary noncardiac pediatric ICU. The data collection forms were completed by a bedside airway team after a tracheal intubation was performed. Day and night care teams were also interviewed to make sure all procedures related to advanced airway management were detailed. Explicit operational definitions were established to analyze the data collected for the presence of unwanted tracheal intubation-associated events. During a 15-month period of evaluation, 200 initial intubation encounters were reported, with 1 occurring every 2.3 days. Oxygenation failure and ventilation failure were the two most common reasons for requiring an airway intervention. More than half (57.4 percent) of first tracheal intubation attempts were performed by a fellow, followed by a resident (34.5 percent), and an attending physician (6.1 percent). The majority of first-course intubations were done by the oral route (91.9 percent). There were 38 unwanted tracheal intubation-association events reported for a rate of 19.3 percent. However, severe events were rare, occurring only in six cases. Factors such as the patient's age, difficult airway history, and attempts by a resident did not influence the occurrence of any events.

Nishisaki, A., Nguyen, J., Colborn, S., and others (2012). "Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit." Pediatric Critical Care Medicine 12(4), pp. 406-414.

In this study, every morning, a pediatric ICU on-call resident, a pediatric ICU nurse, and a respiratory therapist received a brief simulation-based multidisciplinary airway management training session. Following the development of an assessment tool, trained observers rated the training sessions as well as actual intubations in the pediatric ICU. The tool measured both technical skills and behavioral performance. Airway teams consisting of two or more simulation-trained members performed significantly better during actual intubations when compared to teams with less than two trained members. Technical, behavioral, and total scores were higher for these teams. Overall intubation success rates (defined as fewer than 3 attempts) were 89 percent for teams with two or more trained members and 67 percent for teams with fewer than two trained members. In addition, the teams with two or more trained members had no unwanted tracheal intubation-associated events, while the teams with fewer than two trained members had one event.

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