Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting

Abstract

BackgroundIntubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes.MethodsAn interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence.ResultsWe evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99).ConclusionsConformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.

Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations

“…We did observe a high rate of equipment failures as well as an association of equipment failures with TIAEs. Quality improvement initiatives may improve success rates and reduce TIAEs ( 15 ). The frequency of TIAEs was reduced in one center following implementation of an intubation checklist and a time-out procedure ( 16 ).…”

Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis

“…Mosier et al assessed the effectiveness of a high-fidelity simulation programme for critical care fellows and showed an improvement in first-attempt success from 74% before training to 82% after training 9. A retrospective study of paediatric emergency intubations reported conformance to an established process model was associated with higher success rates and less adverse events 10. A previous Australian study by Fogg et al 11 demonstrated successful implementation of their airway bundle (including staff training and standardisation of equipment and practice) with improved first-attempt success rate from 83.4% to 93.9%.…”

Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative

“…As noted, successful initiatives with similar interventions have been reported in other settings, albeit over a shorter time frame. 11 , 12 …”

“…Our findings are also generally consistent with the literature on improving the performance of emergency intubation. [11][12][13][14][15][16][17] These studies took a similar, checklist-or algorithm-based approach, and the magnitude of improvement was comparable. None of these studies, however, examined performance for more than 24 months.…”