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Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An
Akira Nishisaki1, Anthony Lee2, Simon Li3
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
A tracheal intubation safety bundle significantly reduced adverse events in pediatric intensive care units (PICUs). This quality improvement intervention demonstrated sustained effectiveness over 24 months.
Area of Science:
- Pediatric critical care medicine
- Quality improvement science
- Patient safety research
Background:
- Tracheal intubation in pediatric intensive care units (PICUs) is associated with significant adverse events.
- Standardizing intubation procedures is crucial for improving patient outcomes.
Purpose of the Study:
- To evaluate the impact of a tracheal intubation safety bundle on adverse events in PICUs.
- To assess the sustained effectiveness of a quality improvement intervention for tracheal intubation.
Main Methods:
- A multicenter time-series study was conducted across 15 PICUs in the United States.
- A tracheal intubation safety bundle, including performance reports and airway safety checklists, was implemented.
- Data were collected from January 2013 to December 2015, analyzing event rates across different implementation phases.
Main Results:
- Fifteen out of 19 participating PICUs achieved bundle adherence (>80% checklist use).
- Adverse tracheal intubation-associated event rates decreased significantly compared to baseline, with an odds ratio of 0.63 (p=0.001) in the sustained adherence phase.
- Secondary outcomes like severe events, multiple attempts, and hypoxemia also showed improvement.
Conclusions:
- Effective implementation of the tracheal intubation safety bundle led to a significant reduction in adverse events.
- The observed decrease in adverse events was sustained for up to 24 months post-implementation.
- This quality improvement initiative highlights the importance of standardized safety bundles in pediatric critical care.
Objectives:
To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs.
Design:
Multicenter time-series study.
Setting:
PICUs in the United States.
Patients:
All patients received tracheal intubations in ICUs.
Interventions:
We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months.
Measurements And Main Results:
The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001).
Conclusions:
Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.
