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

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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.