Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators.

OBJECTIVES: To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. DESIGN: Multicenter time-series study. SETTING: PICUs in the United States. PATIENTS: All patients received tracheal intubations in ICUs. INTERVENTIONS: We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). CONCLUSIONS: Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.

Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events.

OBJECTIVES: Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. DESIGN: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. SETTING: Forty international PICUs participating in the National Emergency Airway Registry for Children. PATIENTS: Critically ill children 0-17 years old who underwent tracheal intubation in a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. CONCLUSIONS: Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.

Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters.

OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains. DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017. SETTING: Multicenter study conducted in 33 PICUs across eight countries. SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation. INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions. MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008). CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

The New Trainee Effect in Tracheal Intubation Procedural Safety Across PICUs in North America: A Report From National Emergency Airway Registry for Children.

OBJECTIVES: Tracheal intubation carries a high risk of adverse events. The current literature is unclear regarding the "New Trainee Effect" on tracheal intubation safety in the PICU. We evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation associated events. We hypothesize 1) PICUs with pediatric critical care medicine fellowship programs have more adverse tracheal intubation associated events during the first quarter (July-September) of the academic year compared with the rest of the year and 2) tracheal intubation associated event rates and first attempt success performed by pediatric critical care medicine fellows improve through the 3-year clinical fellowship. DESIGN: Retrospective cohort study. SETTING: Thirty-seven North American PICUs participating in National Emergency Airway Registry for Children. PATIENTS: All patients who underwent tracheal intubations in the PICU from July 2013 to June 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The occurrence of any tracheal intubation associated events during the first quarter of the academic year (July-September) was compared with the rest in four different types of PICUs: PICUs with fellows and residents, PICUs with fellows only, PICUs with residents only, and PICUs without trainees. For the second hypothesis, tracheal intubations by critical care medicine fellows were categorized by training level and quarter for 3 years of fellowship (i.e., July-September of 1st yr pediatric critical care medicine fellowship = first quarter, October-December of 1st yr pediatric critical care medicine fellowship = second quarter, and April-June during 3rd year = 12th quarter). A total of 9,774 tracheal intubations were reported. Seven-thousand forty-seven tracheal intubations (72%) were from PICUs with fellows and residents, 525 (5%) with fellows only, 1,201 (12%) with residents only, and 1,001 (10%) with no trainees. There was no difference in the occurrence of tracheal intubation associated events in the first quarter versus the rest of the year (all PICUs: July-September 14.9% vs October-June 15.2%; p = 0.76). There was no difference between these two periods in each type of PICUs (all p ≥ 0.19). For tracheal intubations by critical care medicine fellows (n = 3,836), tracheal intubation associated events significantly decreased over the fellowship: second quarter odds ratio 0.64 (95% CI, 0.45-0.91), third quarter odds ratio 0.58 (95% CI, 0.42-0.82), and 12th quarter odds ratio 0.40 (95% CI, 0.24-0.67) using the first quarter as reference after adjusting for patient and device characteristics. First attempt success significantly improved during fellowship: second quarter odds ratio 1.39 (95% CI, 1.04-1.85), third quarter odds ratio 1.59 (95% CI, 1.20-2.09), and 12th quarter odds ratio 2.11 (95% CI, 1.42-3.14). CONCLUSIONS: The New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.

Short-Term Adverse Outcomes Associated With Hypoglycemia in Critically Ill Children.

OBJECTIVES: Previous studies report worse short-term outcomes with hypoglycemia in critically ill children. These studies relied on intermittent blood glucose measurements, which may have introduced detection bias. We analyzed data from the Heart And Lung Failure-Pediatric INsulin Titration trial to determine the association of hypoglycemia with adverse short-term outcomes in critically ill children. DESIGN: Nested case-control study. SETTING: Thirty-five PICUs. A computerized algorithm that guided the timing of blood glucose measurements and titration of insulin infusion, continuous glucose monitors, and standardized glucose infusion rates were used to minimize hypoglycemia. PATIENTS: Nondiabetic children with cardiovascular and/or respiratory failure and hyperglycemia. Cases were children with any hypoglycemia (blood glucose < 60 mg/dL), whereas controls were children without hypoglycemia. Each case was matched with up to four unique controls according to age group, study day, and severity of illness. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 112 (16.0%) of 698 children who received the Heart And Lung Failure-Pediatric INsulin Titration protocol developed hypoglycemia, including 25 (3.6%) who developed severe hypoglycemia (blood glucose < 40 mg/dL). Of these, 110 cases were matched to 427 controls. Hypoglycemia was associated with fewer ICU-free days (median, 15.3 vs 20.2 d; p = 0.04) and fewer hospital-free days (0 vs 7 d; p = 0.01) through day 28. Ventilator-free days through day 28 and mortality at 28 and 90 days did not differ between groups. More children with insulin-induced versus noninsulin-induced hypoglycemia had zero ICU-free days (35.8% vs 20.9%; p = 0.008). Outcomes did not differ between children with severe versus nonsevere hypoglycemia or those with recurrent versus isolated hypoglycemia. CONCLUSIONS: When a computerized algorithm, continuous glucose monitors and standardized glucose infusion rates were used to manage hyperglycemia in critically ill children with cardiovascular and/or respiratory failure, severe hypoglycemia (blood glucose < 40 mg/dL) was uncommon, but any hypoglycemia (blood glucose < 60 mg/dL) remained common and was associated with worse short-term outcomes.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry.

OBJECTIVE: Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events. DESIGN: A multicenter retrospective cohort study. SETTING: Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative. PATIENTS: Primary tracheal intubation in children younger than 18 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics. CONCLUSIONS: Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National Emergency Airway Registry for Children.

OBJECTIVES: Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU. DESIGN: A retrospective cohort study of a multicenter pediatric airway quality improvement registry. SETTINGS: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036). CONCLUSIONS: Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.

Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs.

OBJECTIVES: Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events. DESIGN: Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014. SETTING: International PICUs. PATIENTS: Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs. INTERVENTIONS: tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia. MEASUREMENTS AND MAIN RESULTS: A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001). CONCLUSIONS: In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children.

OBJECTIVES: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. DESIGN: A retrospective observational study using a multicenter emergency airway quality improvement registry. SETTING: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. MEASUREMENTS AND MAIN RESULTS: Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001). CONCLUSIONS: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Quality improvement in pediatrics: past, present, and future.

Almost two decades ago, the landmark report "To Err is Human" compelled healthcare to address the large numbers of hospitalized patients experiencing preventable harm. Concurrently, it became clear that the rapidly rising cost of healthcare would be unsustainable in the long-term. As a result, quality improvement methodologies initially rooted in other high-reliability industries have become a primary focus of healthcare. Multiple pediatric studies demonstrate remarkable quality and safety improvements in several domains including handoffs, catheter-associated blood stream infections, and other serious safety events. While both quality improvement and research are data-driven processes, significant differences exist between the two. Research utilizes a hypothesis driven approach to obtain new knowledge while quality improvement often incorporates a cyclic approach to translate existing knowledge into clinical practice. Recent publications have provided guidelines and methods for effectively reporting quality and safety work and improvement implementations. This review examines not only how quality improvement in pediatrics has led to improved outcomes, but also looks to the future of quality improvement in healthcare with focus on education and collaboration to ensure best practice approaches to caring for children.

Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes.

OBJECTIVE: Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality. STUDY DESIGN: Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%. SETTING: PICUs participating in NEAR4KIDS. PATIENTS: All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed. MEASUREMENTS AND MAIN RESULTS: Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58-229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1-7 yr and 18% for 8-17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4-21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24-2.60; p = 0.002), after adjusted for patient confounders. CONCLUSIONS: Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.

Increased Occurrence of Tracheal Intubation-Associated Events During Nights and Weekends in the PICU.

OBJECTIVES: Adverse tracheal intubation-associated events are common in PICUs. Prior studies suggest provider and practice factors are important contributors to tracheal intubation-associated events. Little is known about how the incidence of tracheal intubation-associated events is affected by the time of day, day of the week, or presence of in-hospital attending-level intensivists. We hypothesize that tracheal intubations occurring during nights and weekends are associated with a higher frequency of tracheal intubation-associated events. DESIGN: Retrospective observational cohort study. SETTING: Twenty international PICUs. SUBJECTS: Critically ill children requiring tracheal intubation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 5,096 tracheal intubation courses from July 2010 to March 2014 from the prospective multicenter National Emergency Airway Registry for Children. Frequency of a priori-defined tracheal intubation-associated events was the primary outcome. Occurrence of any tracheal intubation-associated events and severe tracheal intubation-associated events were more common during nights (19:00 to 06:59) and weekends compared with weekdays (19% vs 16%, p = 0.01; 7% vs 6%, p = 0.05, respectively). This difference was significant in emergent intubations after adjusting for site-level clustering and patient factors: for any tracheal intubation-associated events: adjusted odds ratio, 1.20; 95% CI, 1.02-1.41; p = 0.03; but not significant in nonemergent intubations: adjusted odds ratio, 0.94; 95% CI, 0.63-1.40; p = 0.75. For emergent intubations, PICUs with home-call attending coverage had a significantly higher frequency of tracheal intubation-associated events during nights and weekends (adjusted odds ratio, 1.29; 95% CI, 1.01-1.66; p = 0.04), and this difference was attenuated in PICUs with in-hospital attending coverage (adjusted odds ratio, 1.12; 95% CI, 0.91-1.39; p = 0.28). CONCLUSIONS: Higher occurrence of tracheal intubation-associated events was observed during nights and weekends. This difference was primarily attributed to emergent intubations. In- hospital attending physician coverage attenuated this discrepancy between weekdays versus nights and weekends but was not fully protective for tracheal intubation-associated events.

Detection of Multiple Respiratory Viruses Associated With Mortality and Severity of Illness in Children.

OBJECTIVE: Respiratory viral infection is a common source of morbidity and mortality in children. Coinfection with multiple viruses occurs frequently; however, the clinical significance of concomitant viral pathogens is unclear. We hypothesized that presence of more than one respiratory virus is associated with increased morbidity and mortality when compared with children with a single respiratory virus. DESIGN: Retrospective cohort study. SETTING: A tertiary care hospital. PATIENTS: All children at Duke Children's Hospital over a 2-year period with isolation of a virus on an extended viral respiratory panel result. Demographic data, comorbidities, and details of hospital encounter were recorded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two hundred thirty-five hospital encounters demonstrated positive extended viral respiratory panels. Immunocompromised status (37%) and respiratory comorbidities (23%) were common. Twenty-eight patients (12%) tested positive for multiple viruses, with adenovirus (23/28) and respiratory syncytial virus (15/28) most prevalent in patients with multiple viruses. Viral codetection was associated with increased use of noninvasive ventilation (p = 0.02), extracorporeal membrane oxygenation (p = 0.02), increased likelihood of moderate or severe illness (p = 0.005), and increased mortality (p = 0.01). Subgroup analysis demonstrated that this mortality association persisted for children with normal immune function (p = 0.003) and children with no comorbidities (p = 0.007). CONCLUSIONS: Children with multiple respiratory viruses may be at increased risk of moderate or severe illness and mortality, with previously healthy children potentially being at greatest risk. Further studies are indicated to determine the significance and generalizability of this finding and to better understand the pathophysiology of viral coinfection.

Standardizing postoperative PICU handovers improves handover metrics and patient outcomes.

OBJECTIVES: To improve handover communication and patient outcomes for postoperative admissions to a multidisciplinary PICU. DESIGN: Prospective cohort study. SETTING: Multidisciplinary PICU in a university hospital. SUBJECTS: The multidisciplinary team responsible for postoperative PICU admissions and patient care, including attending, fellow, house staff physicians, and nurses from pediatric critical care medicine, surgery, and anesthesia. INTERVENTIONS: An online survey distributed to PICU, surgery, and anesthesia providers identified existing barriers and challenges to effective postoperative PICU handovers and guided the formation of a standard protocol. Handovers for postoperative PICU admissions were then directly observed for 3 months pre- and postimplementation of the protocol, with data collected on communication, metrics, and patient outcomes. Observations and data collection, as well as the online provider survey, were repeated approximately 1 year after handover protocol implementation. MEASUREMENTS AND MAIN RESULTS: Survey data demonstrated increases in provider ratings of handover attendance, communication, and quality after implementation of the handover protocol (p < 0.001). Surgical report errors were eliminated (p = 0.03), and the prevalence of provider attendance for the handover duration increased from 39.3% to 68.2% (p = 0.01). Following protocol implementation, fewer patients experienced antibiotic delays (34.5% to 13.9%; p = 0.03) or required hemodynamic or respiratory interventions within the first 6 hours of PICU admission (24.6% to 9.1%; p = 0.04). Patients received their first dose of analgesia (62.3 to 17.4 min; p = 0.01) and had their admission laboratory studies sent (42.3 to 32.9 min; p = 0.04) more quickly. Data collected at 12 months postimplementation demonstrated sustained reductions in analgesia timing, antibiotic delays, and handover barriers. CONCLUSIONS: Postoperative communication and patient outcomes can be improved and sustained over time with implementation of a standardized handover protocol.

Survey of in-house coverage by pediatric intensivists: characterization of 24/7 in-hospital pediatric critical care faculty coverage*.

OBJECTIVE: To characterize the current state of 24/7 in-hospital pediatric intensivist coverage in academic PICUs, including perceptions of faculty and trainees regarding the advantages and disadvantages of in-hospital coverage. DESIGN: Cross-sectional observational study via web-based survey. SETTING: PICUs at North American academic institutions. SUBJECTS: Pediatric intensivists, pediatric critical care fellows, and pediatric residents. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 1,323 responses were received representing a center response rate of 74% (147 of 200). Ninety percent of respondents stated that in-hospital coverage is good for patient care, and 85% stated that in-hospital coverage provides safer care. Sixty-three percent of intensivists stated that working in in-hospital models limits academic productivity, and 65% stated that in-hospital models interfere with nonclinical responsibilities. When compared with intensivists in home coverage models, intensivists working in in-hospital models generally had more favorable perceptions of the effects of in-hospital on patient care (p < 0.0001) and faculty quality of life. Physician burnout was measured with the abbreviated Maslach Burnout Inventory. Although 57% of intensivists responded that working in in-hospital models increases burnout risk, burnout scores were not different between coverage models. Seventy-nine percent of intensivists currently working at institutions with in-hospital coverage stated that they would prefer to work in an in-hospital coverage model, compared with 31% of those working in a home coverage model (p < 0.0001). CONCLUSIONS: Although concerns exist regarding the effect of 24/7 in-hospital coverage on faculty, the majority of pediatric intensivists and critical care trainees responded that in-hospital coverage by intensivists is good for patient care. The majority of intensivists also state that they would prefer to work at an institution with in-hospital coverage. Further research is needed to objectively delineate the effects of in-hospital coverage on both patients and faculty.

Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012).

OBJECTIVE: To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure. DATA SOURCE: A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations. STUDY SELECTION: Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation. DATA EXTRACTION: Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies. DATA SYNTHESIS: Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained. CONCLUSIONS: Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.