Breathing Easier: Decreasing Tracheal Intubation-associated Adverse Events in the Pediatric ED and Urgent Care

Rapid cycle deliberate practice to improve airway skills and performance of trainees in a pediatric emergency department

Objective

The study objective was to determine the effect of a rapid cycle deliberate practice (RCDP) program on simulated and actual airway skills by pediatric emergency medicine (PEM) fellows.

Methods

We designed and implemented a 12-month RCDP airway skills curriculum for PEM fellows at an academic pediatric institution. The curriculum was designed using airway training literature, RCDP principals, and internal quality assurance airway video review program. Simulation training scenarios increased in complexity throughout the curriculum. PEM fellows participated in monthly sessions. Two PEM faculty facilitated the sessions, utilizing a step-by-step objective structured clinical evaluation (OSCE)-style tool for each scenario. Data were collected for all four levels of the Kirkpatrick Model of Training Evaluation-participant response (reaction, pre-post session survey), skills performance in the simulation setting (learning, pre-post OSCE), skills performance for actual patients (behavior, video review), and patient outcomes (results, video review).

Results

During the study period (August 2021 to June 2022), 13 PEM fellows participated in 112 sessions (mean nine sessions per fellow). PEM fellows reported improved comfort in all domains of airway management, including intubation performance. Participant OSCE scores improved posttraining (pretraining median score for trainees 57 [IQR 57-59], posttraining median 61 [IQR 61-62], p = 0.0005). Over the 12 months, PEM fellows performed 45 intubation attempts in the pediatric emergency department (median patient age 4 years [IQR 1-9 years]). Compared to a 5-year historical cohort, participants had higher first-pass success (87% vs. 71%, p = 0.028) and shorter attempt duration (22 s vs. 29 s, p = 0.018). There was no significant difference in the frequency of oxyhemoglobin desaturation in the training period versus the historical period (7% vs. 15%, p = 0.231).

Conclusions

At multiple levels of educational outcomes, including participant behavior and patient outcomes, an RCDP program was associated with improved airway skills and performance of PEM fellows.

Simulation-Facilitated Education for Pediatric Critical Care Nurse Practitioners' Airway Management Skills: A 10-Year Experience

This study aimed to describe the process of the development and implementation with report of our 10-year experience with a simulation-facilitated airway management curriculum for pediatric acute care nurse practitioners in a large academic pediatric intensive care unit. This is a retrospective observational study. The study was conducted at a single-center quaternary noncardiac pediatric intensive care unit in an urban children's hospital in the United States. A pediatric critical care airway management curriculum for nurse practitioners consisting 4 hours of combined didactic and simulation-facilitated education followed by hands-on experience in the operating room. Tracheal intubations performed by nurse practitioners in the pediatric intensive care unit were tracked by a local quality improvement database, NEAR4KIDS from January 2009 to December 2018. Since curriculum initiation, 39 nurse practitioners completed the program. Nurse practitioners functioned as the first provider to attempt intubation in 473 of 3,128 intubations (15%). Also, 309 of 473 (65%) were successful at first attempt. Implementation of a simulation-facilitated pediatric airway management curriculum successfully supported the ongoing airway management participation and first attempt intubation success by nurse practitioners in the pediatric intensive care unit over the 10-year period.

Improvement of Pediatric Advanced Airway Management in General Emergency Departments After a Collaborative Intervention Program

BACKGROUND

In general emergency departments, advanced airway management of pediatric patients who are critically ill has been associated with increased adverse events given the varying exposure to pediatric patients and limited resources. Previous studies have shown significant improvement of simulated pediatric airway management in general emergency departments. The aim of this retrospective study was to determine the effect of an in situ simulation-based collaborative intervention program on the actual care of pediatric airway management in general emergency departments.

METHODS

This was a retrospective study of pediatric subjects who were critically ill and required intubation at a diverse set of general emergency departments before referral to the academic medical center. The primary outcome was the quality of clinical care measured by adherence to best practices via a critical action checklist. Secondary outcomes included tracheal intubation associated adverse events and clinical outcomes.

RESULTS

A total of 135 pediatric subjects (48 pre- and 87 post-intervention) who were transferred to the academic medical center from 9 general emergency departments between May 2014 and August 2019 were included in the analysis. The use of a cuffed endotracheal tube improved, from 44% to 72% (P = .001), whereas there was no significant change in the appropriate endotracheal tube size. Overall, severe tracheal intubation associated adverse events decreased, from 18.8% to 9.2% (P = .03), and post-intubation cardiac arrest events decreased, from 6.3% to 0% (P = .02).

CONCLUSIONS

A simulation-based collaborative intervention program led to improvement in pediatric airway management and subject outcomes in general emergency departments. This model demonstrated the transfer of improvement from a simulated setting to a clinical setting and may be targeted in other clinical settings.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.