Improving the Safety of Pediatric Tracheal Intubations in ICUs with Apneic Oxygenation and Video Laryngoscopes

使用呼吸暂停供氧和视频喉镜提高 ICU 儿童气管插管的安全性

• 批准号: 9258411
• 负责人: AKIRA NISHISAKI
• 金额: $ 24.76万
• 依托单位: CHILDREN'S HOSP OF PHILADELPHIA
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-04-08 至 2020-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9258411
• 关键词: Improving; Safety; Pediatric; Tracheal; Intubations

 DESCRIPTION (provided by applicant): Tracheal intubation (TI) is a commonly performed life-saving procedure for critically ill children, but associated with frequent complications and adverse safety outcomes. With prior AHRQ and Pediatric Acute Lung Injury and Sepsis Investigator (PALISI) network support, we conducted a robust risk assessment using our multi-center pediatric TI safety registry: National Emergency Airway Registry for Children (NEAR4KIDS). We implemented a first generation TI quality improvement QI bundle including: 1) a TI risk factor checklist, 2) a bedside "time-out" immediately before TI, 3) a bedside "time-out" immediately after TI to debrief, and 4) quantitative debriefing among participating centers to share best practices. The evaluation of the clinical impact of this QI bundled intervention is ongoing with promising preliminary results (adverse TI associated event rate dropped from 19% to 16% across all NEAR4KIDS sites). However, with this QI implementation process, we have identified two precursor events: hypoxemia and multiple TI attempts, which need to be addressed to further improve TI safety. In this project, we will implement two easily adoptable interventions: apneic oxygenation (administration of oxygen throughout TI procedure via nasal cannula) and primary use of video laryngoscopes to reduce adverse TI associated events by minimizing hypoxemia and multiple attempts. This project will rigorously evaluate the clinical impact of this second generation QI intervention across a diverse spectrum of (large and small, academic and private) pediatric ICUs. Further, this project will identify and mitigate new QI practice uptake, adoption, implementation processes and variances at the site level. This approach includes standardized outcome measures using our NEAR4KIDS registry, measures of new QI practice uptake, a novel cumulative sum (CUSUM) analysis to track each site's performance prospectively, focus groups with sharp end multidisciplinary providers, and semi-structured interviews with site QI leaders. We will employ mixed- method quantitative and qualitative analyses to identify the key factors and barriers for this second generation bundled QI intervention adoption. Based on these analyses, we will further refine the QI implementation approach. The clinical impact of the implementation of apneic oxygenation and primary use of video laryngoscope will be measured prospectively by our NEAR4KIDS registry process of care measures, and most importantly by a meaningful absolute risk reduction in adverse TI associated events. Our NEAR4KIDS network has grown from 16 sites to 28 sites over last 2 years. At the completion of the this project, we have access to large implementation networks including PALISI and the American Heart Association life support training programs, who are poised to disseminate the findings beyond these 28 centers. Upon successful completion, we will understand the feasibility, barriers, and clinical impact of apneic oxygenation and video laryngoscopy on high-risk, but life-saving, TI procedural safety outcomes.

 描述（由申请人提供）：气管插管（TI）是危重儿童常用的救生手术，但与频繁的并发症和不良安全性结局相关。在之前的AHRQ和儿科急性肺损伤和脓毒症研究者（PALISI）网络支持下，我们使用我们的多中心儿科TI安全登记研究：国家儿童紧急气道登记研究（NEAR4KIDS）进行了一项稳健的风险评估。我们实施了第一代TI质量改进QI包，包括：1）TI风险因素检查表，2）TI前立即进行床边“暂停”，3）TI后立即进行床边“暂停”以进行汇报，以及4）参与中心之间的定量汇报， 分享最佳做法。目前正在对这种QI捆绑干预的临床影响进行评估，初步结果令人鼓舞（所有NEAR4KIDS研究中心的不良TI相关事件发生率从19%降至16%）。然而，在此QI实施过程中，我们已经确定了两个前兆事件：低氧血症和多次TI尝试，需要解决这些问题以进一步提高TI安全性。 在本项目中，我们将实施两种易于采用的干预措施：呼吸暂停氧合（通过鼻插管在整个TI手术中给予氧气）和主要使用视频喉镜，通过最大限度地减少低氧血症和多次尝试来减少不良TI相关事件。该项目将严格评估第二代QI干预在不同范围（大型和小型，学术和私人）儿科ICU中的临床影响。此外，该项目将确定和缓解新的QI实践的吸收、采用、实施过程和现场层面的差异。这种方法包括使用我们的NEAR4KIDS注册表的标准化结果测量，新的QI实践吸收的测量，一种新的累积总和（CANUUM）分析，以前瞻性地跟踪每个站点的性能，与尖端多学科提供者的焦点小组，以及与站点QI领导者的半结构化访谈。我们将采用定量和定性的混合方法分析，以确定采用第二代捆绑式QI干预措施的关键因素和障碍。基于这些分析，我们将进一步完善QI实施方法。实施呼吸暂停氧合和主要使用视频喉镜的临床影响将通过我们的NEAR4KIDS登记研究护理措施过程进行前瞻性测量，最重要的是通过不良TI相关事件的有意义的绝对风险降低进行测量。在过去的两年里，我们的NEAR4KIDS网络从16个站点增长到28个站点。在这个项目完成后，我们可以访问大型实施网络，包括PALISI和美国心脏协会生命支持培训计划，他们准备将研究结果传播到这28个中心之外。成功完成后，我们将了解呼吸暂停氧合和视频喉镜对高风险但可挽救生命的TI手术安全性结局的可行性、障碍和临床影响。