Benjamin T. Kerrey

Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review

STUDY OBJECTIVE Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED). METHODS We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success. RESULTS We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. CONCLUSION Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries

STUDY OBJECTIVE We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

A Prospective Comparison of Diaphragmatic Ultrasound and Chest Radiography to Determine Endotracheal Tube Position in a Pediatric Emergency Department

BACKGROUND. Investigators report endotracheal tube misplacement in up to 40% of emergent intubations. The standard elements of confirmation have significant limitations. Diaphragmatic ultrasound is a potentially viable addition to the confirmatory process. Our primary hypothesis is that ultrasound is equivalent to chest radiography in determining endotracheal tube position within the airway in emergent pediatric intubations. METHODS. We enrolled a prospective, convenience sample from all intubated patients in our emergency department. The primary outcome was the agreement between diaphragmatic ultrasound and chest radiography for endotracheal tube position. On ultrasound, tracheal placement equaled bilateral diaphragmatic motion, bronchial placement equaled unilateral diaphragmatic motion, and esophageal placement equaled no or paradoxical diaphragmatic motion during delivery of positive pressure. Study sonographers were blind to radiographic results. Our secondary outcome was the timeliness of ultrasound versus chest radiography results. Our institutional review board approved this study with a waiver of informed consent. RESULTS. One hundred twenty-seven patients were enrolled. In 24 (19%) patients, the endotracheal tube was in the mainstem bronchus on chest radiography. There were no esophageal intubations in the sample. Ultrasound and chest radiography agreed on endotracheal tube placement in 106 patients (94 tracheal and 12 mainstem), for an overall agreement of 0.83. The sensitivity of ultrasound for tracheal placement was 0.91. The specificity of ultrasound for mainstem intubation was 0.50. Thirty-four patients had a second ultrasound by a separate, blinded sonographer; 33 of 34 of the results of the second sonographer were in agreement with the initial sonogram, for an interrater agreement of 97%. Clinically useful chest radiography results took a median of 8 minutes longer to achieve than ultrasound results. CONCLUSIONS. Diaphragmatic ultrasound was not equivalent to chest radiography for endotracheal tube placement within the airway. However, ultrasound results were timelier, detected more misplacements than standard confirmation alone, and were highly reproducible between sonographers.

The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View

STUDY OBJECTIVE We seek to provide current, comprehensive, and physician-level data for critical procedures performed in a high-volume pediatric emergency department (ED). METHODS We conducted a retrospective study of all critical procedures performed in the ED of a tertiary care pediatric institution. Data were collected from written records of resuscitative care provided. The primary outcome measure was the cumulative frequency of each critical procedure during 12 consecutive months. Additional outcome measures included the number of critical procedures performed by pediatric emergency medicine faculty and fellows and a description of the other physician types performing each procedure. RESULTS Two hundred sixty-one critical procedures were performed during 194 patient resuscitations, which represented 0.22% of all ED patient evaluations. Sixty-one percent of pediatric emergency medicine faculty did not perform a single critical procedure. Orotracheal intubation occurred 147 times and represented 56% of all critical procedures, yet 63% of pediatric emergency medicine faculty did not perform a single successful orotracheal intubation. Pediatric emergency medicine fellows performed a median of 3 critical procedures. CONCLUSION Critical procedures were rarely performed in a large, academic pediatric ED. Pediatric emergency medicine faculty are at significant risk for skill deterioration, and pediatric emergency medicine fellows are unlikely to achieve competence in the performance of critical procedures if clinical exposure is the sole basis for the attainment and maintenance of skill.

Teamwork skills in actual, in situ, and in-center pediatric emergencies: performance levels across settings and perceptions of comparative educational impact.

Introduction Pediatric emergencies require effective teamwork. These skills are developed and demonstrated in actual emergencies and in simulated environments, including simulation centers (in center) and the real care environment (in situ). Our aims were to compare teamwork performance across these settings and to identify perceived educational strengths and weaknesses between simulated settings. We hypothesized that teamwork performance in actual emergencies and in situ simulations would be higher than for in-center simulations. Methods A retrospective, video-based assessment of teamwork was performed in an academic, pediatric level 1 trauma center, using the Team Emergency Assessment Measure (TEAM) tool (range, 0–44) among emergency department providers (physicians, nurses, respiratory therapists, paramedics, patient care assistants, and pharmacists). A survey-based, cross-sectional assessment was conducted to determine provider perceptions regarding simulation training. Results One hundred thirty-two videos, 44 from each setting, were reviewed. Mean total TEAM scores were similar and high in all settings (31.2 actual, 31.1 in situ, and 32.3 in-center, P = 0.39). Of 236 providers, 154 (65%) responded to the survey. For teamwork training, in situ simulation was considered more realistic (59% vs. 10%) and more effective (45% vs. 15%) than in-center simulation. Discussion In a video-based study in an academic pediatric institution, ratings of teamwork were relatively high among actual resuscitations and 2 simulation settings, substantiating the influence of simulation-based training on instilling a culture of communication and teamwork. On the basis of survey results, providers favored the in situ setting for teamwork training and suggested an expansion of our existing in situ program.

Interobserver Agreement in the Clinical Assessment of Children With Blunt Abdominal Trauma

OBJECTIVES The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma. METHODS This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement. RESULTS A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation. CONCLUSIONS Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.

A Multicenter Study of the Risk of Intra-Abdominal Injury in Children After Normal Abdominal Computed Tomography Scan Results in the Emergency Department

STUDY OBJECTIVE We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in the emergency department (ED) after blunt torso trauma. METHODS This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention. RESULTS Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%). CONCLUSION In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.

Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging

BACKGROUND Gastrostomy tube (g-tube) dislodgement is a common problem in special needs children. There are no studies on the frequency of complications after g-tube replacement for children in a pediatric emergency department (ED). OBJECTIVES The objective of this study is to determine the frequency of misplacement and subsequent complications for children undergoing g-tube replacement in a pediatric ED and the impact of contrast-enhanced confirmatory imaging on ED length of stay (LOS). METHODS This was a retrospective review of children presenting to a pediatric ED over 16 months. Subjects were included if they underwent g-tube replacement in the ED. Records were reviewed for historical and procedural data including patient age, g-tube age, ED LOS, documented difficulties replacing the tube, performance of confirmatory imaging (contrast-enhanced radiograph), and complications identified within 72 hours of ED visit. RESULTS A total of 237 children met inclusion criteria. Three (1.2%) had evidence of g-tube misplacement, all of whom underwent confirmatory imaging. One complication from misplacement was identified (gastric outlet obstruction from overfilled balloon). Tract disruption was not identified for any subject. Eighty-four subjects (35%) had confirmatory imaging performed after replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P < .001). No subjects with documentation of clinical confirmation had subsequent evidence of misplacement. CONCLUSIONS For children undergoing g-tube replacement in a pediatric ED, misplacement and associated complications were rare. Confirmatory imaging was associated with a considerably longer LOS. In the presence of clinical confirmation, confirmatory imaging may be judiciously used.

Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department

Objectives Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2<90%). This report describes a multidisciplinary initiative to improve the performance and safety of RSI in a paediatric ED. Methods We conducted a local improvement initiative in a high-volume academic paediatric ED. We simultaneously tested: (1) an RSI checklist, (2) a pilot/copilot model for checklist execution, (3) the use of a video laryngoscope and (4) the restriction of laryngoscopy to specific providers. Data were collected primarily by video review during the testing period and the historical period (2009–2010, baseline). We generated statistical process control charts (G-charts) to measure change in the performance of six key processes, attempt failure and the occurrence of oxyhaemoglobin desaturation during RSI. We iteratively revised the four interventions through multiple plan-do-study-act cycles within the Model for Improvement. Results There were 75 cases of RSI during the testing period (July 2012–September 2013). Special cause variation occurred on the G-charts for three of six key processes, attempt failure and desaturation, indicating significant improvement. The frequency of desaturation was 50% lower in the testing period than the historical (16% vs 33%). When all six key processes were performed, only 6% of patients experienced desaturation. Conclusions Following the simultaneous introduction of four interventions in a paediatric ED, RSI was performed more reliably, successfully and safely.

Simulation to Implement a Novel System of Care for Pediatric Critical Airway Obstruction

OBJECTIVE To implement a novel system of care for pediatric critical airway obstruction. DESIGN Retrospective, observational study of data gathered prospectively during high-fidelity simulations. SETTING Emergency department (ED) and operating rooms (ORs) of a pediatric referral center. SUBJECTS Health care provider simulation participants. MAIN OUTCOME MEASURES Time from ED attending physician request to arrival of an otolaryngologist, participant survey responses, identified latent safety threats, and simulated patient outcomes. METHODS Twelve high-fidelity simulations were conducted: 6 to identify problems with an existing system of care, and 6 to implement a novel system. The simulation scenarios involved a 4-year-old patient with severe respiratory distress after foreign-body aspiration managed solely in the ED or in the ED and OR, depending on stability. RESULTS There were 196 participants in 12 simulations. The mean (SD) time from ED attending physician request to otolaryngologist arrival was 7.8 (1.6) minutes for the existing system simulations and 5.0 (1.1) minutes for the novel system (P = .001). Latent safety threats identified in the simulations included a lack of specialized airway equipment in the ED. Death of the simulated patient occurred in the ED in 2 of 6 existing system simulations; specialized airway equipment was available for neither. For the novel system simulations, specialized airway equipment was available for all 6, no simulated patient deaths occurred. CONCLUSIONS High-fidelity simulation was an effective method to design and implement a novel system of care for pediatric critical airway obstruction. The novel system was associated with more rapid response times and elimination of simulated patient deaths.