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

 描述(由申请人提供)：气管插管(TI)是危重儿童常见的救命手术，但与频繁的并发症和不良的安全后果有关。在之前的AHRQ和儿科急性肺损伤和败血症调查员(PALISI)网络的支持下，我们使用我们的多中心儿科TI安全登记系统：国家儿童急救呼吸道登记系统(NEAR4KIDS)进行了稳健的风险评估。我们实施了第一代TI质量改进QI包，包括：1)TI风险因素核对表，2)在TI之前的床边“暂停”，3)在TI之后的床边“暂停”汇报，以及4)参与中心之间的定量汇报，以 分享最佳实践。对这种QI捆绑干预的临床影响的评估正在进行中，初步结果令人振奋(所有NEAR4KID站点的不良TI相关事件发生率从19%下降到16%)。然而，在这个QI实施过程中，我们已经确定了两个先兆事件：低氧血症和多次TI尝试，这两个事件需要解决，以进一步提高TI的安全性。在这个项目中，我们将实施两种易于采用的干预措施：呼吸暂停氧合(通过鼻腔插管在整个TI手术过程中给氧)和初步使用视频喉镜，通过最大限度地减少低氧血症和多次尝试来减少与TI相关的不良事件。该项目将严格评估这种第二代QI干预措施在不同范围(大小、学术和私人)的儿科ICU中的临床影响。此外，该项目将确定和减少现场一级新的质量改进实践的采用、采用、实施过程和差异。这种方法包括使用我们的NEAR4KID注册的标准化结果测量，新的QI实践吸收的测量，一个新的累积和(CUSUM)分析，以前瞻性地跟踪每个站点的表现，与尖端多学科提供者的焦点小组，以及对站点QI领导者的半结构化访谈。我们将使用混合方法、定量和定性分析来确定第二代捆绑QI干预采用的关键因素和障碍。在这些分析的基础上，我们将进一步完善QI实施方法。实施窒息氧合和首次使用视频喉镜的临床影响将通过我们的NEAR4KID注册护理措施过程进行前瞻性评估，最重要的是通过有意义的不良感染相关事件的绝对风险降低来衡量。在过去的两年中，我们的NEAR4KIDS网络从16个站点发展到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。在成功完成后，我们将了解窒息氧合和视频喉镜在高危但挽救生命的TI手术安全结局中的可行性、障碍和临床影响。

 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.