Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department.

OBJECTIVES: Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2<90%). This report describes a multidisciplinary initiative to improve the performance and safety of RSI in a paediatric ED. METHODS: We conducted a local improvement initiative in a high-volume academic paediatric ED. We simultaneously tested: (1) an RSI checklist, (2) a pilot/copilot model for checklist execution, (3) the use of a video laryngoscope and (4) the restriction of laryngoscopy to specific providers. Data were collected primarily by video review during the testing period and the historical period (2009-2010, baseline). We generated statistical process control charts (G-charts) to measure change in the performance of six key processes, attempt failure and the occurrence of oxyhaemoglobin desaturation during RSI. We iteratively revised the four interventions through multiple plan-do-study-act cycles within the Model for Improvement. RESULTS: There were 75 cases of RSI during the testing period (July 2012-September 2013). Special cause variation occurred on the G-charts for three of six key processes, attempt failure and desaturation, indicating significant improvement. The frequency of desaturation was 50% lower in the testing period than the historical (16% vs 33%). When all six key processes were performed, only 6% of patients experienced desaturation. CONCLUSIONS: Following the simultaneous introduction of four interventions in a paediatric ED, RSI was performed more reliably, successfully and safely.

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department.

OBJECTIVE: Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than lab-based training, and reinforce teamwork training in a paediatric emergency department (ED). METHODS: Multidisciplinary healthcare providers responded to critical simulated patients in an urban ED during all shifts. Unannounced in situ simulations were limited to 10 min of simulation and 10 min of debriefing, and were video recorded. A standardised debriefing template was used to assess LSTs. The primary outcome measure was the number and type of LSTs identified during the simulations. Secondary measures included: participants' assessment of impact on patient care and value to participants. Blinded video review using a modified Anaesthetists Non-Technical Skills scale was used to assess team behaviours. RESULTS: 218 healthcare providers responded to 90 in situ simulations conducted over 1 year. A total of 73 LSTs were identified; a rate of one every 1.2 simulations performed. In situ simulations were cancelled at a rate of 28% initially, but the cancellation rate decreased as training matured. Examples of threats identified include malfunctioning equipment and knowledge gaps concerning role responsibilities. 78% of participants rated the simulations as extremely valuable or valuable, while only 5% rated the simulation as having little or no value. Of those responding to a postsimulation survey, 77% reported little or no clinical impact. Video recordings did not indicate changes in non-technical skills during this time. CONCLUSIONS: In situ simulation is a practical method for the detection of LSTs and to reinforce team training behaviours. Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting.

A prospective comparison of diaphragmatic ultrasound and chest radiography to determine endotracheal tube position in a pediatric emergency department.

BACKGROUND: Investigators report endotracheal tube misplacement in up to 40% of emergent intubations. The standard elements of confirmation have significant limitations. Diaphragmatic ultrasound is a potentially viable addition to the confirmatory process. Our primary hypothesis is that ultrasound is equivalent to chest radiography in determining endotracheal tube position within the airway in emergent pediatric intubations. METHODS: We enrolled a prospective, convenience sample from all intubated patients in our emergency department. The primary outcome was the agreement between diaphragmatic ultrasound and chest radiography for endotracheal tube position. On ultrasound, tracheal placement equaled bilateral diaphragmatic motion, bronchial placement equaled unilateral diaphragmatic motion, and esophageal placement equaled no or paradoxical diaphragmatic motion during delivery of positive pressure. Study sonographers were blind to radiographic results. Our secondary outcome was the timeliness of ultrasound versus chest radiography results. Our institutional review board approved this study with a waiver of informed consent. RESULTS: One hundred twenty-seven patients were enrolled. In 24 (19%) patients, the endotracheal tube was in the mainstem bronchus on chest radiography. There were no esophageal intubations in the sample. Ultrasound and chest radiography agreed on endotracheal tube placement in 106 patients (94 tracheal and 12 mainstem), for an overall agreement of 0.83. The sensitivity of ultrasound for tracheal placement was 0.91. The specificity of ultrasound for mainstem intubation was 0.50. Thirty-four patients had a second ultrasound by a separate, blinded sonographer; 33 of 34 of the results of the second sonographer were in agreement with the initial sonogram, for an interrater agreement of 97%. Clinically useful chest radiography results took a median of 8 minutes longer to achieve than ultrasound results. CONCLUSIONS: Diaphragmatic ultrasound was not equivalent to chest radiography for endotracheal tube placement within the airway. However, ultrasound results were timelier, detected more misplacements than standard confirmation alone, and were highly reproducible between sonographers.