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Dean P, Geis G, Hoehn EF, Lautz AJ, Edmunds K, Shah A, Zhang Y, Frey M, Boyd S, Nagler J, Miller KA, Neubrand TL, Cabrera N, Kopp TM, Wadih E, Kannikeswaran N, VanDeWall A, Hewett Brumberg EK, Donoghue A, Palladino L, O'Connell KJ, Mazzawi M, Tam DCF, Murray M, Kerrey B. High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence. Resuscitation 2023; 190:109875. [PMID: 37327848 DOI: 10.1016/j.resuscitation.2023.109875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.
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Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Gary Geis
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Erin F Hoehn
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Division of Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - Andrew J Lautz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Joshua Nagler
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Kelsey A Miller
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Tara L Neubrand
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States.
| | - Natasha Cabrera
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Tara M Kopp
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Esper Wadih
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Audrey VanDeWall
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Elizabeth K Hewett Brumberg
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Aaron Donoghue
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Lauren Palladino
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Malek Mazzawi
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Derek Chi Fung Tam
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Matthew Murray
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Benjamin Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
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2
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Prekker ME, Bjorklund AR, Myers C, Harvey L, Horton GB, Goldstein J, Usher SC, Reardon RF, Robinson A, Strobel AM, Driver BE. The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children. Ann Emerg Med 2023; 81:667-676. [PMID: 36841658 DOI: 10.1016/j.annemergmed.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE Bougie use during emergency tracheal intubation has not been well studied in children. METHODS This was a 10-year observational study of pediatric intubations (<18 years of age) in the emergency department (ED) of an academic institution. Bougie training and use are standard in our ED, including for emergency medicine residents. Study data were collected by a combination of charts and video reviews. We compare first-attempt intubation success and procedural complications between pediatric patients with and without bougie use during tracheal intubation in the ED. In addition, we evaluate the independent association of bougie use with first-attempt intubation success using multivariable logistic regression. RESULTS We collected data on intubation success and bougie use for 195 pediatric patients over more than 10 years. On the first tracheal intubation attempt, a pediatric bougie was used in 126 patients (65%). Median patient age was 5 years (interquartile range 1.7 to 9) in the bougie group and 1.7 years (interquartile range 0.2 to 5) in the no bougie group. Intubation was successful on the first attempt in 72% of intubations with a bougie versus 78% without a bougie (absolute difference -6%, 95% confidence interval [CI] -19 to 6%); the adjusted odds of first-attempt success with a bougie were 0.54 (95% CI 0.24 to 1.19). A procedural complication occurred for 38% of patients in the bougie group versus 51% in the no bougie group (-13%, 95% CI -27% to 2%). Two neonates, one in each group, experienced a potential injury to the airway or lower respiratory tract. CONCLUSION In an academic ED where the bougie is commonly used, bougie use in children was not associated with procedural success or complications. Our study suggests that a randomized clinical trial is needed to determine the effect of bougie use during emergency pediatric intubation.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hennepin County Medical Center.
| | - Ashley R Bjorklund
- Division of Pediatric Critical Care, Department of Pediatrics, Hennepin County Medical Center, and the University of Minnesota, M Health Masonic Children's Hospital
| | - Carrie Myers
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Lauren Harvey
- Department of Emergency Medicine, Hennepin County Medical Center
| | | | - Jack Goldstein
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Sarah C Usher
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Aaron Robinson
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Ashley M Strobel
- Division of Emergency Medicine and Child Advocacy, Department of Pediatrics, University of Minnesota, M Health Masonic Children's Hospital, Minneapolis, MN
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center
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3
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Hayes-Bradley C, Tarrant M. Rocuronium ≤1.5 mg/kg versus >1.5 mg/kg and inadequate paralysis in prehospital and retrieval intubation: A retrospective study. Emerg Med Australas 2022; 34:892-897. [PMID: 35649634 DOI: 10.1111/1742-6723.14008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/16/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Greater Sydney Area Helicopter Emergency Medical Service encouraged an increased dose of rocuronium for rapid sequence intubations (RSIs) from 1.5 mg/kg to 2.0 mg/kg from the end of 2017 in response to a number of inadequately paralysed patients identified by our airway audit processes. Subsequent protocol change incorporated 2.0 mg/kg rocuronium. This retrospective observational study was undertaken to see if doses over 1.5 mg/kg rocuronium were associated with a reduction in the number of inadequately paralysed patients. METHODS Retrospective review of patient prehospital notes and airway database records from 2017 to 2018 for all cases using rocuronium for RSI. Primary outcome of interest was physician notes describing skeletal muscle activity at laryngoscopy. Patients with tissued vascular access were excluded. Dose of rocuronium, estimated patient actual weight and grade of laryngoscopy were recorded. Comparisons were made between rocuronium doses ≤1.5 mg/kg and >1.5 mg/kg by estimated weight. RESULTS From 211 patients receiving rocuronium ≤1.5 mg/kg, five cases were inadequately paralysed, compared with two cases from 384 patients receiving >1.5 mg/kg rocuronium. CONCLUSIONS Although there were fewer inadequately paralysed patients with rocuronium doses >1.5 mg/kg, this did not reach statistical significance, presumably because of the low event rate. Further investigation into rocuronium dose for RSI is warranted.
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Affiliation(s)
- Clare Hayes-Bradley
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance, Sydney, New South Wales, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Madelaine Tarrant
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance, Sydney, New South Wales, Australia
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4
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Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative. Ann Emerg Med 2022; 79:333-343. [DOI: 10.1016/j.annemergmed.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/14/2021] [Accepted: 12/21/2021] [Indexed: 12/31/2022]
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Shah A, Edmunds K, Dean P, Frey M, Boyd S, Ahaus K, Zhang Y, Varadarajan K, Kerrey BT. Don't Hold Your Breath-A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation. Pediatr Emerg Care 2022; 38:e784-e790. [PMID: 35100777 DOI: 10.1097/pec.0000000000002340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED). DESIGN This was a retrospective, observational study of RSI. SETTING An academic PED. PATIENTS A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019. MEASUREMENT AND MAIN RESULTS Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, -10.5; 95% confidence interval [CI], -17.0 to -4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, -3.5; 95% CI, -8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, -12.5; 95% CI, -17.0 to -4.0). These results did not change when adjusting for age or clustering by provider. CONCLUSIONS We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.
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Affiliation(s)
| | | | - Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Karen Ahaus
- University of Cincinnati College of Medicine
| | - Yin Zhang
- University of Cincinnati College of Medicine
| | - Kartik Varadarajan
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
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Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative. Pediatr Qual Saf 2021; 6:e385. [PMID: 34963998 PMCID: PMC8702256 DOI: 10.1097/pq9.0000000000000385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/18/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative.
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7
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Dean P, Edmunds K, Shah A, Frey M, Zhang Y, Boyd S, Kerrey BT. Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department. Ann Emerg Med 2021; 79:323-332. [PMID: 34952729 DOI: 10.1016/j.annemergmed.2021.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance. METHODS We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model. RESULTS From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90). CONCLUSION We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.
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Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, San Diego, CA
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yin Zhang
- Division of Emergency Medicine, and the Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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8
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Abid ES, Miller KA, Monuteaux MC, Nagler J. Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department. Emerg Med J 2021; 39:601-607. [PMID: 34872932 DOI: 10.1136/emermed-2021-211570] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/13/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting. OBJECTIVE We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations. DESIGN AND METHODS We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors. RESULTS During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy. CONCLUSION Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.
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Affiliation(s)
- Edir S Abid
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Bakhsh A, Alharbi A, Almehmadi R, Kamfar S, Aldhahri A, Aledeny A, Ashour Y, Khojah I. Improving first-pass success rates during emergency intubation at an academic emergency department: a quality improvement initiative. Int J Qual Health Care 2021; 33:6366349. [PMID: 34494654 DOI: 10.1093/intqhc/mzab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Airway management is a high-stakes procedure in emergency medicine. Continuously monitoring this procedure allows performance improvement while revealing safety issues. We instituted a quality improvement initiative in the emergency department to improve first-pass success rates in the emergency department. METHODS This was a quality improvement initiative at an academic emergency department from 2018 to 2020. We developed a rapid sequence intubation guideline for procedure standardization and introduced an intubation procedure note for performance monitoring. Data were entered directly by the primary physician and nurse during intubation. The quality improvement team thereafter collected the data retrospectively and entered into a local airway database. More importantly, we introduced a culture of quality improvement and safety in airway management via regular education and feedback. RESULTS We included a total of 146 intubations. The first-pass success rate started at 57.1% and increased to 80.0% during the study period (P < 0.01). Fifty-six percent were male, and the mean age (±SD) was 55.56 (±17.64). Video laryngoscopy was used in 101 (69.2%) patients, while direct laryngoscopy was used in only 44 (30.8%) patients. A logistic regression analysis was conducted to determine the independent factors associated with first-pass success. These factors included the use of video laryngoscopy (odds ratio (OR) 2.47 95% confidence interval (95% CI) [1.62-3.76]) (adjusted OR 3.87 [1.13-13.23]) and good Cormack-Lehane views (grades 1-2) (OR 2.71 95% CI [1.74-4.20]) (adjusted OR 7.88 [2.43-25.53]). CONCLUSION Our study shows that implementing and maintaining an airway quality improvement program improves first-pass intubation success. Moreover, the use of video laryngoscopy and obtaining good Cormack-Lehane views (grades 1-2) are independently associated with improved first-pass success.
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Affiliation(s)
- Abdullah Bakhsh
- Department of Emergency Medicine, King Abdulaziz University Hospital, P.O. Box 80215, Jeddah 21589, Saudi Arabia
| | - Ahd Alharbi
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Raghad Almehmadi
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Sara Kamfar
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Arwa Aldhahri
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Ahmed Aledeny
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Yasmeen Ashour
- Department of Total Quality Management, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Imad Khojah
- Department of Emergency Medicine, King Abdulaziz University Hospital, P.O. Box 80215, Jeddah 21589, Saudi Arabia
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10
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Nauka PC, Chen JT, Shiloh AL, Eisen LA, Fein DG. Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic. Chest 2021; 160:2112-2122. [PMID: 34139207 PMCID: PMC8204844 DOI: 10.1016/j.chest.2021.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 01/15/2023] Open
Abstract
Background For patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure. Research Question For patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic? Study Design and Methods We conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables. Results One thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01). Interpretation Video laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.
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Affiliation(s)
- Peter C Nauka
- Internal Medicine Residency Program, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Jen-Ting Chen
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Ariel L Shiloh
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Lewis A Eisen
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Daniel G Fein
- Division of Pulmonary Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY.
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11
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Mittiga MR, Frey M, Kerrey BT, Rinderknecht AS, Eckerle MD, Sobolewski B, Johnson LH, Oehler JL, Bennett BL, Chan S, Frey TM, Krummen KM, Lindsay C, Wolfangel K, Richert A, Masur TJ, Bria CL, Hoehn EF, Geis GL. The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:167-171. [PMID: 30883536 DOI: 10.1097/pec.0000000000001742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
ABSTRACT Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.
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Affiliation(s)
| | - Mary Frey
- From the Division of Emergency Medicine
| | | | | | | | | | | | | | | | | | | | - Kelly M Krummen
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Claire Lindsay
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Kelsey Wolfangel
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Alison Richert
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Tonya J Masur
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
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Dean PN, Hoehn EF, Geis GL, Frey ME, Cabrera‐Thurman MK, Kerrey BT, Zhang Y, Stalets EL, Zackoff MW, Maxwell AR, Pham TM, Lautz AJ. Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department. Acad Emerg Med 2020; 27:1241-1248. [PMID: 32896033 DOI: 10.1111/acem.14128] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED). METHODS This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria. RESULTS Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively. CONCLUSIONS We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.
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Affiliation(s)
- Preston N. Dean
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Erin F. Hoehn
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- the Division of Emergency Medicine Children's Hospital of Pittsburgh of UPMC Pittsburgh PAUSA
| | - Gary L. Geis
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Mary E. Frey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Mary K. Cabrera‐Thurman
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Benjamin T. Kerrey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Yin Zhang
- the Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Erika L. Stalets
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Matthew W. Zackoff
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrea R. Maxwell
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Tena M. Pham
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrew J. Lautz
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
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Fein DG, Zhao D, Swartz K, Nauka P, Andrea L, Aboodi M, Shiloh AL, Eisen LA. The Impact of Nighttime on First Pass Success During the Emergent Endotracheal Intubation of Critically Ill Patients. J Intensive Care Med 2020; 36:1498-1506. [PMID: 33054483 DOI: 10.1177/0885066620965166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND While numerous investigations have described worse outcomes for patients undergoing emergent procedures at night, few studies have investigated the impact of nighttime on the outcomes of emergent endotracheal intubation (EEI). We hypothesized that for patients requiring EEI at night, the outcome of first pass success would be lower as compared to during the day. METHODS We performed a retrospective cohort study of all patients admitted to our institution between January 1st, 2016 and July 17st, 2019 who underwent EEI outside of an emergency department or operating room. Nighttime was defined as between 7:00 pm and 6:59 am. The primary outcome was the rate of first pass success. Logistic regression was utilized with adjustment for demographic, morbidity and procedure related covariables. RESULTS The final examined cohort included 1,674 EEI during the day and 1,229 EEI at night. The unadjusted rate of first pass success was not different between the day and night (77.5% vs. 74.6%, unadjusted odds ratio (OR): 0.85; 95% confidence interval (CI): 0.72, 1.0; P = 0.073 though following adjustment for prespecified covariables the odds of first pass success was lower at night (adjusted OR: 0.83, 95% CI: 0.69, 0.99; P = 0.042. Obesity was found to be an effect modifier on first pass success rate for day vs. night intubations. In obese patients, nighttime intubations had significantly lower odds of first pass success (adjusted OR: 0.71, 95% CI: 0.52, 0.98; P = 0.037). DISCUSSION After adjustment for patient and procedure related factors, we have found that the odds of first pass success is lower at night as compared to the day. This finding was, to some degree, driven by obesity which was found to be a significant effect modifier in this relationship.
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Affiliation(s)
- Daniel G Fein
- Division of Pulmonary Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dawn Zhao
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kyle Swartz
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Peter Nauka
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luke Andrea
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Aboodi
- Division of Pulmonary and Critical Care Medicine, Cornell University Joan and Sanford I Weill Medical College, New York, NY, USA
| | - Ariel L Shiloh
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lewis A Eisen
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Optimizing Rapid Sequence Intubation for Medical and Trauma Patients in the Pediatric Emergency Department. Pediatr Qual Saf 2020; 5:e353. [PMID: 33062904 PMCID: PMC7523837 DOI: 10.1097/pq9.0000000000000353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/23/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Rapid sequence intubation (RSI) is a critical procedure for severely ill and injured patients presenting to the pediatric emergency department (PED). This procedure has a high risk of complications, and multiple attempts increase this risk. We aimed to increase successful intubation within two attempts, focusing on medical and trauma patients separately to identify improvement barriers for each group. Methods A multifaceted intervention was implemented using quality improvement methods. The analysis included adherence to the standardized process, successful intubation within two attempts, and frequency of oxygen saturations <92% during laryngoscopy. Trauma and medical patients were analyzed separately as team composition differed for each. Results This project began in February 2018, and we included 290 patients between April 2018 and December 2019. Adherence to the standardized process was sustained at 91% for medical patients and a baseline of 55% for trauma patients with a trend toward improvement. In May 2018, we observed and sustained special cause variations for medical patients' successful intubations within two attempts (77-89%). In September 2018, special cause variation was observed and sustained for the successful intubation of trauma patients within two attempts (89-96%). The frequency of oxygen saturation of <92% was 21% for medical patients; only one trauma patient experienced oxygen desaturation. Conclusion Implementation of a standardized process significantly improved successful intubations within two attempts for medical and trauma patients. Trauma teams had more gradual adherence to the standardized process, which may be related to the relative infrequency of intubations and variable team composition.
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Analysis of CPR quality by individual providers in the pediatric emergency department. Resuscitation 2020; 153:37-44. [PMID: 32505613 DOI: 10.1016/j.resuscitation.2020.05.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/23/2020] [Accepted: 05/19/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To describe chest compression (CC) quality by individual providers in two pediatric emergency departments (EDs) using video review and compression monitor output during pediatric cardiac arrests. METHODS Prospective observational study. Patients <18 yo receiving CC for >1 min were eligible. Data was collected from video review and CC monitor device in a synchronized fashion and reported in 'segments' by individual providers. Univariate comparison by age (<1 yo, 1-8 yo, >8 yo) was performed by chi-square testing for dichotomous variables ('high-quality' CPR) and nonparametric testing for continuous variables (CC rate and depth). Univariate comparison of ventilation rate (V) was made between segments with an advanced airway versus without. RESULTS 524 segments had data available; 42/524 (8%) met criteria for 'high-quality CC'. Patients >8 yo had more segments meeting criteria (18% vs. 2% and 0.5%; p < 0.001). Segments compliant for rate were less frequent in <1 yo (17% vs. 24% vs. 27%; p = 0.03). Segments compliant for depth were less frequent in <1 year olds and 1-8 year olds (5% and 9% vs. 20%, p < 0.001.) Mean V for segments with an advanced airway was higher than with a natural airway (24 ± 18 vs. 14 ± 10 bpm, p < 0.001). Hyperventilation was more prevalent in CPR segments with an advanced airway (66% vs. 32%, p < 0.001). CONCLUSIONS CC depth is rarely guideline compliant in infants. Hyperventilation is more prevalent during CPR periods with an advanced airway in place. Measuring individual provider CPR quality is feasible, allowing future studies to evaluate the impact of CPR training.
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Videography in Pediatric Emergency Research: Establishing a Multicenter Collaborative and Resuscitation Registry. Pediatr Emerg Care 2020; 36:222-228. [PMID: 32356959 DOI: 10.1097/pec.0000000000001531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES High-quality clinical research of resuscitations in a pediatric emergency department is challenging because of the limitations of traditional methods of data collection (chart review, self-report) and the low frequency of cases in a single center. To facilitate valid and reliable research for resuscitations in the pediatric emergency department, investigators from 3 pediatric centers, each with experience completing successful single-center, video-based studies, formed the Videography In Pediatric Emergency Research (VIPER) collaborative. METHODS Our initial effort was the development of a multicenter, video-based registry and simulation-based testing of the feasibility and reliability of the VIPER registry. Feasibility of data collection was assessed by the frequency of an indeterminate response for all data elements in the registry. Reliability was assessed by the calculation of Cohen κ for dichotomous data elements and intraclass correlation coefficients for continuous data elements. RESULTS Video-based data collection was completed for 8 simulated pediatric resuscitations, with at least 2 reviewers per case. Data were labeled as indeterminate by at least 1 reviewer for 18 (3%) of 524 relevant data fields. The Cohen κ for all dichotomous data fields together was 0.81 (95% confidence interval, 0.61-1.0). For all continuous (time-based) variables combined, the intraclass correlation coefficient was 0.88 (95% confidence interval, 0.70-0.96). CONCLUSIONS Initial simulation-based testing suggests video-based data collection using the VIPER registry is feasible and reliable. Our next step is to assess feasibility and reliability for actual pediatric resuscitations and to complete several prospective, hypothesis-based studies of specific aspects of resuscitative care, including of cardiopulmonary resuscitation, tracheal intubation, and teamwork and communication.
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Kerrey BT, Wang H. Intubation by Emergency Physicians: How Often Is Enough? Ann Emerg Med 2019; 74:795-796. [PMID: 31439364 DOI: 10.1016/j.annemergmed.2019.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Benjamin T Kerrey
- University of Cincinnati, College of Medicine, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Henry Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, TX
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18
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Breathing Easier: Decreasing Tracheal Intubation-associated Adverse Events in the Pediatric ED and Urgent Care. Pediatr Qual Saf 2019; 4:e230. [PMID: 32010856 PMCID: PMC6946226 DOI: 10.1097/pq9.0000000000000230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/05/2019] [Indexed: 12/12/2022] Open
Abstract
Supplemental Digital Content is available in the text. Tracheal intubation is a high-risk procedure in the pediatric emergency department (PED) and pediatric urgent care (PUC) settings. We aimed to develop an airway safety intervention to decrease severe tracheal intubation-associated adverse events (TIAEs) by decreasing process variation.
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Overmann KM, Boyd SD, Zhang Y, Kerrey BT. Apneic oxygenation to prevent oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department. Am J Emerg Med 2019; 37:1416-1421. [DOI: 10.1016/j.ajem.2018.10.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/09/2018] [Accepted: 10/17/2018] [Indexed: 10/28/2022] Open
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Sakles JC, Augustinovich CC, Patanwala AE, Pacheco GS, Mosier JM. Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program. West J Emerg Med 2019; 20:610-618. [PMID: 31316700 PMCID: PMC6625676 DOI: 10.5811/westjem.2019.4.42343] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/06/2019] [Accepted: 04/20/2019] [Indexed: 01/06/2023] Open
Abstract
Introduction Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period. Methods An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means. Results EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = −7.9%, 95% CI −13.4% to −2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%). Conclusion The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events.
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Affiliation(s)
- John C Sakles
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
| | | | - Asad E Patanwala
- University of Sydney, Faculty of Medicine and Health, Sydney, Australia
| | - Garrett S Pacheco
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
| | - Jarrod M Mosier
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona.,University of Arizona College of Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Tucson, Arizona
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Vukovic AA, Hanson HR, Murphy SL, Mercurio D, Sheedy CA, Arnold DH. Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department. Am J Emerg Med 2018; 37:27-32. [PMID: 29699900 DOI: 10.1016/j.ajem.2018.04.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted. OBJECTIVE Determine association between AO and hypoxemia in pediatric patients undergoing ETI. METHODS Observational study at an urban, tertiary children's hospital emergency department. Pediatric patients undergoing ETI were examined during eras without (January 2011-June 2011) and with (August 2014-March 2017) apneic oxygenation. The primary outcome was hypoxemia, defined as pulse oximetry (SpO2) < 90%. The χ2 and Wilcoxon rank-sum tests examined differences between cohorts. Multivariable regression models examined adjusted associations between covariates and hypoxemia. RESULTS 149 patients were included. Cohorts were similar except for greater incidence of altered mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the pre-AO cohort experienced hypoxemia during ETI, versus <25% in the AO cohort. Median [IQR] lowest SpO2 during ETI was 93 (69, 99) for pre-AO and 100 [95, 100] for the AO cohort (p < 0.001). In a multivariable logistic regression model, hypoxemia during ETI was associated with AO (aOR 0.3, 95% confidence interval [CI] 0.1-0.8), increased age (for 1 year, aOR 0.8, 95% CI 0.7-1.0), lowest SpO2 before ETI (for 1% increase, aOR 0.9, 95% CI 0.8-1.0), and each additional intubation attempt (aOR 4.0, 95% CI 2.2-7.2). CONCLUSIONS Apneic oxygenation is an easily-applied intervention associated with decreases in hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO experienced hypoxemia.
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Affiliation(s)
- Adam A Vukovic
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA.
| | - Holly R Hanson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - Shelley L Murphy
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - Danielle Mercurio
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - Craig A Sheedy
- Department of Emergency Medicine, Vanderbilt University Medical Center, 1313 21st Avenue South, 703 Oxford House, Nashville, TN 37232, USA
| | - Donald H Arnold
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA; Department of Pediatrics, Division of Pulmonary Medicine and the Center for Asthma Research Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN 37232, USA
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Walker RG, White LJ, Whitmore GN, Esibov A, Levy MK, Cover GC, Edminster JD, Nania JM. Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation. PREHOSP EMERG CARE 2018; 22:300-311. [PMID: 29297718 DOI: 10.1080/10903127.2017.1380095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. METHODS Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. RESULTS Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO2 decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. CONCLUSIONS In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.
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Kerrey BT, Rinderknecht A, Mittiga M. High Risk, Low Frequency: Optimizing Performance of Emergency Intubation for Children. Ann Emerg Med 2017; 70:783-786. [DOI: 10.1016/j.annemergmed.2017.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 10/19/2022]
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Sterrett EC, Myer CM, Oehler J, Das B, Kerrey BT. Critical Airway Team: A Retrospective Study of an Airway Response System in a Pediatric Hospital. Otolaryngol Head Neck Surg 2017; 157:1060-1067. [PMID: 28849711 DOI: 10.1177/0194599817719400] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objective Study the performance of a pediatric critical airway response team. Study Design Case series with chart review. Setting Freestanding academic children's hospital. Subjects and Methods A structured review of the electronic medical record was conducted for all activations of the critical airway team. Characteristics of the activations and patients are reported using descriptive statistics. Activation of the critical airway team occurred 196 times in 46 months (March 2012 to December 2015); complete data were available for 162 activations (83%). For 49 activations (30%), patients had diagnoses associated with difficult intubation; 45 (28%) had a history of difficult laryngoscopy. Results Activation occurred at least 4 times per month on average (vs 3 per month for hospital-wide codes). The most common reasons for team activation were anticipated difficult intubation (45%) or failed intubation attempt (20%). For 79% of activations, the team performed an airway procedure, most commonly direct laryngoscopy and tracheal intubation. Bronchoscopy was performed in 47% of activations. Surgical airway rescue was attempted 4 times. Cardiopulmonary resuscitation occurred in 41 activations (25%). Twenty-nine patients died during or following team activation (18%), including 10 deaths associated with the critical airway event. Conclusion Critical airway team activation occurred at least once per week on average. Direct laryngoscopy, tracheal intubation, and bronchoscopic procedures were performed frequently; surgical airway rescue was rare. Most patients had existing risk factors for difficult intubation. Given our rate of serious morbidity and mortality, primary prevention of critical airway events will be a focus of future efforts.
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Affiliation(s)
- Emily C Sterrett
- 1 Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Charles M Myer
- 2 Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,3 Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jennifer Oehler
- 4 James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bobby Das
- 5 Department of Pediatric Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Benjamin T Kerrey
- 6 Center for Stimulation and Research, Cincinnati Children's Hospital Medical Center, Center for Simulation & Research, Cincinnati, Ohio, USA
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25
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Semler MW, Mikkelsen ME. If at First You Don't Succeed: Patient Characteristics Associated with First-Attempt Failure of Video Laryngoscopy in the Intensive Care Unit. Ann Am Thorac Soc 2017; 14:305-306. [PMID: 28248582 PMCID: PMC5427726 DOI: 10.1513/annalsats.201612-1029ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
- Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark E. Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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