A taxonomy of errors for pediatric emergency intubation

Intubation is an infrequent but critical procedure in the Pediatric Emergency Department (PED). Compared to adult intubations, pediatric intubations have additional anatomic and physiologic challenges and are optimally completed in under 45 s. Adult airway literature reports a classification system for intubation errors when reviewing video laryngoscopy (VL) recordings, which provides structure for video review-based quality assurance (QA). We aimed to modify an existing system for pediatrics and determine the frequency of each error.

This prospective, observational study used a convenience sample of successive, de-identified, recorded intubation attempts. Error definitions were codified after reviewing a pilot video set. Subsequent videos were coded for the 12 errors and attempt duration.

100 videos were reviewed. The most common errors were attempting endotracheal tube (ETT) passage with a suboptimal view (42%), inadequate lifting (40%), blade insertion left of midline (26%), lost traction (26%), failure to engage midline structures (25%), and difficulty passing ETT through the vocal cords (24%). 74 attempts were successful, with a median of 1 (Inter Quartile Range (IQR) 0-5) error; unsuccessful attempts had a median of 3 (IQR 2-5) errors (p = 0.01). 60 attempts were successful in under 45 s; of these, 35 (58%) had ≤1 error. All errors in the insertion phase of intubation, as well as inability to reach the cords with the ETT, were significant between successful and unsuccessful attempts (p < 0.05). For successful intubations under 45 s, inadequate lifting, lost traction, and attempting to intubate a suboptimal view were also significant.

This study describes a system to classify pediatric intubations errors and identifies their frequency in a PED. This system can be used to develop a standard intubation QA process, inform ongoing and just-in-time trainee education, and provide individual coaching.