Sholeen Nett

Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the national emergency airway registry for children*.

Objective: Tracheal intubation in PICUs is associated with adverse tracheal intubation–associated events. Patient, provider, and practice factors have been associated with tracheal intubation–associated events; however, site-level variance and the association of site-level characteristics on tracheal intubation–associated event outcomes are unknown. We hypothesize that site-level variance exists in the prevalence of tracheal intubation–associated events and that site characteristics may affect outcomes. Design: Prospective observational cohort study. Setting: Fifteen PICUs in North America. Subjects: Critically ill pediatric patients requiring tracheal intubation. Interventions: None. Measurement and Main Results: Tracheal intubation quality improvement data were collected in 15 PICUs from July 2010 to December 2011 using a National Emergency Airway Registry for Children with robust site-specific compliance. Tracheal intubation–associated events and severe tracheal intubation–associated events were explicitly defined a priori. We analyzed the association of site-level variance with tracheal intubation–associated events using univariate analysis and adjusted for previously identified patient- and provider-level risk factors. Analysis of 1,720 consecutive intubations revealed an overall prevalence of 20% tracheal intubation–associated events and 6.5% severe tracheal intubation–associated events, with considerable site variability ranging from 0% to 44% tracheal intubation–associated events and from 0% to 20% severe tracheal intubation–associated events. Larger PICU size (> 26 beds) was associated with fewer tracheal intubation–associated events (18% vs 23%, p = 0.006), but the presence of a fellowship program was not (20% vs 18%, p = 0.58). After adjusting for patient and provider characteristics, both PICU size and fellowship presence were not associated with tracheal intubation–associated events (p = 0.44 and p = 0.18, respectively). Presence of mixed ICU with cardiac surgery was independently associated with a higher prevalence of tracheal intubation–associated events (25% vs 15%; p < 0.001; adjusted odds ratio, 1.81; 95% CI, 1.29–2.53; p = 0.01). Substantial site-level variance was observed in medication use, which was not explained by patient characteristic differences. Conclusions: Substantial site-level variance exists in tracheal intubation practice, tracheal intubation–associated events, and severe tracheal intubation–associated events. Neither PICU size nor fellowship training program explained site-level variance. Interventions to reduce tracheal intubation–associated event prevalence and severity will likely need to be contextualized to variability in individual ICUs patients, providers, and practice.

Development of a Quality Improvement Bundle to Reduce Tracheal Intubation–Associated Events in Pediatric ICUs

Advanced airway management in the pediatric intensive care unit (PICU) is hazardous, with associated adverse outcomes. This report describes a methodology to develop a bundle to improve quality and safety of tracheal intubations. A prospective observational cohort study was performed with expert consensus opinion of 1715 children undergoing tracheal intubation at 15 PICUs. Baseline process and outcomes data in tracheal intubation were collected using the National Emergency Airway Registry for Children reporting system. Univariate analysis was performed to identify risk factors associated with adverse tracheal intubation–associated events. A multidisciplinary quality improvement committee was formed. Workflow analysis of tracheal intubation and pilot testing were performed to develop the Airway Bundle Checklist with 4 parts: (1) risk factor assessment, (2) plan generation, (3) preprocedure time-out to ensure that providers, equipment, and plans are prepared, (4) postprocedure huddle to identify improvement opportunities. The Airway Bundle Checklist developed may lead to improvement in airway management.

Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes

Objective: Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality. Study Design: Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%. Setting: PICUs participating in NEAR4KIDS. Patients: All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed. Measurements and Main Results: Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58–229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1–7 yr and 18% for 8–17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4–21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24–2.60; p = 0.002), after adjusted for patient confounders. Conclusions: Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.

Biomarkers and genetics of brain injury risk in diabetic ketoacidosis: A pilot study

Diabetic ketoacidosis (DKA) is the primary cause of death for children with diabetes, especially when complicated by cerebral edema. Central nervous system (CNS) involvement is common, however the mechanism of, and predictors of CNS dysfunction/injury are largely unknown. In this observational pilot study, blood was collected from pediatric DKA patients at three time points (consent, 12 hr and 24 hr after beginning treatment), to test genetic markers, ribonucleic acid expression and plasma biomarkers reflecting inflammation (tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and cerebral dysfunction and/or possible injury (S100β, glial fibrillary acidic protein [GFAP]). Thirty patients were enrolled in the study. The average age was 11.3 yr, 73% were new onset diabetes and 53% were female. Forty percent exhibited abnormal mentation (Glasgow Coma Scale <15), consistent with CNS dysfunction. IL-6 and TNF-α were elevated in plasma, suggesting systemic inflammation. GFAP was measurable in 45% of patients and correlated positively with GCS. Only two patients had detectable levels of S100β. In conclusion, children with DKA often present with evidence of acute neurologic dysfunction or injury. We have demonstrated the feasibility of exploring genetic and biochemical markers of potential importance in the pathophysiology of CNS dysfunction and/or possible injury in DKA. We have identified IL-6, TNF-α and GFAP as potentially important markers for further exploration. A larger, follow-up study will help to better understand the extent and type of CNS injury in DKA as well as the mechanism underlying this dysfunction/injury.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children

Objectives: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. Design: A retrospective observational study using a multicenter emergency airway quality improvement registry. Setting: Thirty-five PICUs within general and children’s hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). Patients: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. Measurements and Main Results: Propensity score–matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62–0.75; p < 0.001). In propensity score–matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90–0.95; p < 0.001). Conclusions: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Pediatric Ventilator-associated Infections: The Ventilator-associated Infection Study

Objective: Suspected ventilator-associated infection is the most common reason for antibiotics in the PICU. We sought to characterize the clinical variables associated with continuing antibiotics after initial evaluation for suspected ventilator-associated infection and to determine whether clinical variables or antibiotic treatment influenced outcomes. Design: Prospective, observational cohort study conducted in 47 PICUs in the United States, Canada, and Australia. Two hundred twenty-nine pediatric patients ventilated more than 48 hours undergoing respiratory secretion cultures were enrolled as “suspected ventilator-associated infection” in a prospective cohort study, those receiving antibiotics of less than or equal to 3 days were categorized as “evaluation only,” and greater than 3 days as “treated.” Demographics, diagnoses, comorbidities, culture results, and clinical data were compared between evaluation only and treated subjects and between subjects with positive versus negative cultures. Setting: PICUs in 47 hospitals in the United States, Canada, and Australia. Subjects: All patients undergoing respiratory secretion cultures during the 6 study periods. Interventions: None. Measurements and Main Results: Treated subjects differed from evaluation-only subjects only in frequency of positive cultures (79% vs 36%; p < 0.0001). Subjects with positive cultures were more likely to have chronic lung disease, tracheostomy, and shorter PICU stay, but there were no differences in ventilator days or mortality. Outcomes were similar in subjects with positive or negative cultures irrespective of antibiotic treatment. Immunocompromise and higher Pediatric Logistic Organ Dysfunction scores were the only variables associated with mortality in the overall population, but treated subjects with endotracheal tubes had significantly lower mortality. Conclusions: Positive respiratory cultures were the primary determinant of continued antibiotic treatment in children with suspected ventilator-associated infection. Positive cultures were not associated with worse outcomes irrespective of antibiotic treatment although the lower mortality in treated subjects with endotracheal tubes is notable. The necessity of continuing antibiotics for a positive respiratory culture in suspected ventilator-associated infection requires further study.

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

Objectives: To describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders. Design: Mixed methods. Setting: Thirteen PICUs of the National Emergency Airway Registry for Children network. Intervention: Remote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks. Measurements and Main Results: Bundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182–781). Five sites were early (median, 153 d; interquartile range, 146–267) and eight sites were late adopters (median, 783 d; interquartile range, 773–845). Focus groups identified common “promoter” themes—interdisciplinary approach, influential champions, and quality improvement bundle customization—and “barrier” themes—time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention. Conclusions: Implementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

43: DESATURATION DURING TRACHEAL INTUBATIONS IN PICUS IS PERVASIVE AND ASSOCIATED WITH ADVERSE OUTCOMES

Learning Objectives: The occurrence of desaturation during tracheal Intubations (TI) and the relation to indication and adverse TI associated events (TIAEs) across diverse Pediatric ICUs (PICUs) is unknown. Methods: Data from a multicenter TI database (NEAR4KIDS) across 31 PICUs from 1/2012-12/2014. All primary TIs with SpO2>90% after pre-oxygenation were included. TI indications were classified as: Respiratory (R), Hemodynamic (H), Respiratory+Hemodynamic (RH), or other (O). We defined moderate desaturation as SpO2 <80% and profound desaturation as SpO2 <70% during TI. We evaluated the association between moderate/profound desaturation with occurrence of any adverse TIAEs or severe TIAEs as well as number of attempts on the occurrence of moderate/ profound desaturation. Analysis was by χ2 and multivariate logistic regression. Results: Of 5,754 TIs, moderate desaturation was associated with TI indications: R 22% (755/3357), H 12% (44/359), RH 28% (94/341), O 11% (185/1697), p<0.001. The association of profound desaturation with TI indication were R 16%, H 8%, RH 20%, O 7%, p<0.001. TIs with moderate desaturation (SpO2< 80%), compared to those without, were associated with TIAEs (32% vs. 13%, p<0.001) and severe TIAEs (11% vs. 5%, p<0.001). Profound desaturation (SpO2<70%) was associated with TIAEs (36% vs.13%, p<0.001) and severe TIAEs (12% vs.5%, p<0.001). All findings persisted after adjusting for TI indications (i.e. severe TIAEs OR: 1.9, 95%CI 1.5–2.4 for moderate desaturation, OR: 2.4, 95%CI 1.8–3.1, for profound desaturation). The number of attempts required for a given TI was associated with moderate and profound desaturation (p<0.001). After adjusting for indication, the associations with moderate desaturation were: 2 attempts OR 3.4 (95%CI 2.9–4.0) and 3+ attempts OR 6.7 (95%CI 5.6–8.0), compared with 1 attempt. For profound desaturation the associations were: 2 attempts OR 3.7, 95%CI 3.0–4.5, and 3+ attempts OR 6.9, 95%CI 5.6–8.5. Conclusions: Moderate (SpO2<80%) and profound (SpO2<70%) desaturations are associated with TIAEs. Number of TI attempts is also associated with desaturation during TI.

Improving Handoffs Between Operating Room and Pediatric Intensive Care Teams: Before and After Study

Introduction: Patient transfer between teams and units is known to be a high-risk event for miscommunication and therefore error. We instituted a quality improvement initiative to formalize patient handoffs from the operating room (OR) to the Pediatric Intensive Care Unit (PICU). We hypothesized that measures of information transfer would improve. Methods: In this before and after study, a multidisciplinary team developed a standardized handoff protocol (including a checklist) instituted in the Dartmouth PICU over the summer of 2016. We directly observed pediatric admissions from OR to PICU and collected data on information transfer and patient outcome metrics both before and after the institution of the handoff protocol at the time of transfer (intervention). Results: We directly observed 52 handoffs (29 preintervention, 23 postintervention). The mean patient age was 9.3 years (SD, 6.5), with 55% male. Preintervention the average information transfer was 56% (upper control limit, 76%; lower control limit, 36%), whereas postintervention it was 81% (upper control limit, 97%, lower control limit, 65%). The improvement in information transfer postintervention was statistically significant (P < 0.001). There was no statistically significant change in maximum pain score in the first 6 hours after admission (preintervention, 4.5, SD 3.9; postintervention, 2.9, SD 1.3, P = 0.15). There was no difference in the time required for handoff pre- versus postintervention (8.7 minutes, SD 5.5 versus 10.1 minutes, SD 4.6, P = 0.34). Conclusion: Standardization of OR to PICU patient transfers using a predetermined checklist at the time of handoff can improve the completeness of information transfer without increasing the length of the handoff.

Frequency of Desaturation and Association with Hemodynamic Adverse Events during Tracheal Intubations in PICUs

Objectives: Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation–associated events. Design: Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network’s quality improvement project from January 2012 to December 2014. Setting: International PICUs. Patients: Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs. Interventions: tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation–associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia. Measurements and Main Results: A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation–associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation–associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation–associated events: adjusted odds ratio 1.83 (95% CI, 1.34–2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation–associated events: adjusted odds ratio 2.16 (95% CI, 1.54–3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001). Conclusions: In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.