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

项目摘要 ICU中每10名重症患儿中就有1名需要气管插管（TI）。TI是危险倾向的程序 考虑到需要TI的重症儿童通常氧气储备有限，解剖结构具有挑战性， 危及生命的血流动力学不稳定他们的不良气道结局风险最高[AAO]： 气管插管相关事件（TIAE）和/或重度氧饱和度下降。自2010年以来，国家 由我们团队领导的儿童紧急气道登记（NEAR 4KIDS）合作已经证明， 患有AAO的儿童机械通气时间明显延长，ICU停留时间延长， mortality.我们的儿科ICU气道捆绑与床边检查表减少了AAO。然而， 改进的余地仍然存在。2019年，在54个NEAR 4KIDS儿科ICU中，24%的重症儿童 要求TI仍然经历AAO。为了大大提高危重患儿高危TI的安全性， 必须以最佳技术和人为因素的方法促进床边小组的工作。 我们的总体目标是在各种儿科疾病中改变TI在危重儿童中的安全性和质量 重症监护室我们将通过实施数字化智能清单来实现这一目标，该清单具有三个具体特征： 基于患者特征的提示，直接显示困难气道状态和来自 电子健康记录和基于预测分析的高风险警告。我们将描述 干预对工作流程和系统的影响（即，流程中断、工作流程集成、 团队合作，团队领导者的认知任务量）来确定临床影响的解释因素（即，到 理解如何和为什么）。我们将在6个儿科ICU中实施数字化智能检查表， NEAR 4KIDS采用随机分组设计。智能清单升级将在12个月内进行， 将包括数字转换、提示的引入、完整的EHR集成气道历史显示，以及 风险计算我们的研究团队包括一位经验丰富的EHR临床决策支持程序员 用于多中心使用，具有良好的成功记录。我们制定了明确的实施计划。我们将 检验假设：智能检查表的实施将使AAO的发生率降低27%（相对风险 减少，6%绝对值）。在目标2中，我们将确定如何以及为什么实施智能清单 使用已建立的人为因素方法减少每个ICU的AAO。我们的发现将广泛地 适用于具有各种提供者技能水平的任何程序安全，特别是当程序 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.