Smart checklist implementation for pediatric tracheal intubations in the ICU- multicenter study: SMART PICU

项目摘要 ICU中每10个危重儿童中就有一个需要气管插管(TI)。TIS是容易发生危险的手术 考虑到需要人工授精的危重儿童通常氧气储备有限，具有挑战性的解剖学，以及 危及生命的血流动力学不稳定。他们面临着最高的不良呼吸道后果风险[AAO]： 气管插管相关事件(TIAE)和/或严重的氧气减饱和。自2010年以来，国家 由我们团队领导的儿童紧急航空登记系统(NEAR4KIDS)已经证明 患有AAO的儿童机械通气时间、ICU停留时间和 死亡率。我们的儿科ICU气道捆绑和床边清单减少了AAO。然而，大量的 改进的空间仍然存在。2019年，在54个NEAR4KID儿科ICU中，24%的危重儿童 要求德州仪器仍有AAOS经验。为了大幅提高危重儿童高危感染的安全性， 用最优的技术和人为因素的方法促进床边团队的绩效至关重要。 我们的首要目标是改变不同儿科危重儿童的TI的安全性和质量 重症监护室。我们将通过实施数字化智能核对表实现这一目标，该核对表具有三个具体功能： 基于患者特征的提示，直接显示困难的呼吸道状态和来自 电子健康记录，以及基于预测性分析的高风险警告。我们将描述 干预对工作流程和系统的影响(即，流程中断、工作流整合、 团队合作，团队领导的认知任务)，以确定临床影响的解释因素(即 了解如何以及为什么)。我们将在年内对6个儿科ICU实施数字化智能清单 NEAR4KID采用群集式随机设计。智能核对表升级将在12个月内进行， 将包括数字转换、提示的引入、完全集成EHR的呼吸道历史显示，以及 风险计算。我们的调查团队包括一位经验丰富的eHR临床决策支持程序员 适用于多中心使用，并有良好的成功记录。我们制定了明确的实施计划。我们会 验证假设：实施智能核对表将使AAO的发生率降低27%(相对风险 减少，绝对值为6%)。在目标2中，我们将确定如何以及为什么实施智能核对表 使用既定的人为因素方法减少每个ICU的AAO。我们的发现将广泛应用于 适用于具有不同提供商技能水平的任何程序安全，尤其是在程序 风险很高。

Project Summary One in 10 critically ill children in the ICU requires tracheal intubation (TI). TIs are hazard-prone procedures given that critically ill children who require TI often have limited oxygen reserve, challenging anatomy, and life-threatening hemodynamic instability. They are at the highest risk for Adverse Airway Outcomes [AAO]: Tracheal Intubation Associated Events (TIAE) and/or severe oxygen desaturation. Since 2010, the National Emergency Airway Registry for Children (NEAR4KIDS) collaborative led by our team has demonstrated that children with AAO had significantly longer mechanical ventilation duration, longer ICU stays, and higher mortality. Our pediatric ICU Airway Bundle with bedside checklist reduced the AAO. However, substantial room for improvement still exists. In 2019, across 54 NEAR4KIDS pediatric ICUs, 24% of critically ill children requiring TI still experienced AAOs. To substantially improve the safety of high-risk TI for critically ill children, it is essential to facilitate bedside team performance with optimal technology and a human factors approach. Our overarching goal is to transform the safety and quality of TI in critically ill children across diverse pediatric ICUs. We will achieve this goal by implementing a digitalized Smart Checklist that has three specific features: prompts based on patient characteristics, direct display of difficult airway status and airway information from the electronic health record, and high-risk warning based on predictive analytics. We will characterize the impact of the intervention on work processes and systems (i.e., flow disruptions, workflow integration, teamwork, team leader’s cognitive taskload) to determine explanatory factors for the clinical impact (i.e., to understand how and why). We will implement a digitalized Smart Checklist across 6 Pediatric ICUs within NEAR4KIDS using a cluster-randomized design. Smart Checklist upgrades will take place over 12 months and will include digital conversion, the introduction of prompts, full EHR-integrated airway history display, and risk calculation. Our team of investigators includes an experienced EHR clinical decision support programmer for multicenter use with a robust track record of success. We developed a clear implementation plan. We will test the hypothesis: Smart Checklist implementation will reduce the occurrence of AAO by 27% (relative risk reduction, 6% absolute). In Aim 2, we will determine how and why the Smart Checklist implementation reduces the AAO at each ICU using an established human factors approach. Our findings will be widely applicable in any procedural safety with various provider skill levels, especially when and where the procedural risk is high.