Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting.

BACKGROUND: Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. METHODS: An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence. RESULTS: We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99). CONCLUSIONS: Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.

Errors in cervical spine immobilization during pediatric trauma evaluation.

BACKGROUND: The purpose of this study was to identify factors during trauma evaluation that increase the likelihood of errors in cervical spine immobilization ('lapses'). MATERIALS AND METHODS: Multivariate analysis was used to identify the associations between patient characteristics, event features, and tasks performed in proximity to the head and neck and the occurrence and duration of a lapse in maintaining cervical spine immobilization during 56 pediatric trauma evaluations. RESULTS: Lapses in cervical spine immobilization occurred in 71.4% of patients (n = 40), with an average of 1.2 ± 1.3 lapses per patient. Head and neck tasks classified as oxygen manipulation occurred an average of 12.2 ± 9.7 times per patient, whereas those related to neck examination and cervical collar manipulation occurred an average of 2.7 ± 1.7 and 2.1 ± 1.2 times per patient, respectively. More oxygen-related tasks were performed among patients who had than those who did not have a lapse (27.3 ± 16.5 versus 11.5 ± 8.0 tasks, P = 0.001). Patients who had cervical collar placement or manipulation had a two-fold higher risk of a lapse than those who did not have these tasks performed (OR 1.92, 95% CI 0.56, 3.28, P = 0.006). More lapses occurred during evaluations on the weekend (P = 0.01), when more tasks related to supplemental oxygen manipulation were performed (P = 0.02) and when more tasks associated with cervical collar management were performed (P < 0.001). CONCLUSIONS: Errors in cervical spine immobilization were frequently observed during the initial evaluation of injured children. Strategies to reduce these errors should target approaches to head and neck management during the primary and secondary phases of trauma evaluation.

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation.

BACKGROUND: Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm because of mitigation or chance may have similar causation and are more frequent than those causing adverse outcomes. Analyzing these error types is an alternative to adverse outcome analysis. The purpose of this study was to identify errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence. METHODS: Errors identified using video analysis were classified as errors of omission or commission and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared. RESULTS: Thirty-nine resuscitations were reviewed, identifying 337 errors (range, 2-26 per resuscitation). The most common errors were related to cervical spine stabilization (n = 93, 27.6%). Errors of omission (n = 135) and commission (n = 106) were more common than errors of selection (n = 96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p = 0.03 and p = 0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p = 0.004 and p = 0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features. CONCLUSIONS: Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation. LEVEL OF EVIDENCE: Therapeutic study, level III.

Association Between Trauma Center Type and Mortality Among Injured Adolescent Patients.

IMPORTANCE: Although data obtained from regional trauma systems demonstrate improved outcomes for children treated at pediatric trauma centers (PTCs) compared with those treated at adult trauma centers (ATCs), differences in mortality have not been consistently observed for adolescents. Because trauma is the leading cause of death and acquired disability among adolescents, it is important to better define differences in outcomes among injured adolescents by using national data. OBJECTIVES: To use a national data set to compare mortality of injured adolescents treated at ATCs, PTCs, or mixed trauma centers (MTCs) that treat both pediatric and adult trauma patients and to determine the final discharge disposition of survivors at different center types. DESIGN, SETTING, AND PARTICIPANTS: Data from level I and II trauma centers participating in the 2010 National Trauma Data Bank (January 1 to December 31, 2010) were used to create multilevel models accounting for center-specific effects to evaluate the association of center characteristics (PTC, ATC, or MTC) on mortality among patients aged 15 to 19 years who were treated for a blunt or penetrating injury. The models controlled for sex; mechanism of injury (blunt vs penetrating); injuries sustained, based on the Abbreviated Injury Scale scores (post-dot values <3 or ≥3 by body region); initial systolic blood pressure; and Glasgow Coma Scale scores. Missing data were managed using multiple imputation, accounting for multilevel data structure. Data analysis was conducted from January 15, 2013, to March 15, 2016. EXPOSURES: Type of trauma center. MAIN OUTCOMES AND MEASURES: Mortality at each center type. RESULTS: Among 29 613 injured adolescents (mean [SD] age, 17.3 [1.4] years; 72.7% male), most were treated at ATCs (20 402 [68.9%]), with the remainder at MTCs (7572 [25.6%]) or PTCs (1639 [5.5%]). Adolescents treated at PTCs were more likely to be injured by a blunt than penetrating injury mechanism (91.4%) compared with those treated at ATCs (80.4%) or MTCs (84.6%). Mortality was higher among adolescents treated at ATCs and MTCs than those treated at PTCs (3.2% and 3.5% vs 0.4%; P < .001). The adjusted odds of mortality were higher at ATCs (odds ratio, 4.19; 95% CI, 1.30-13.51) and MTCs (odds ratio, 6.68; 95% CI, 2.03-21.99) compared with PTCs but was not different between level I and II centers (odds ratio, 0.76; 95% CI, 0.59-0.99). CONCLUSION AND RELEVANCE: Mortality among injured adolescents was lower among those treated at PTCs, compared with those treated at ATCs and MTCs. Defining resource and patient features that account for these observed differences is needed to optimize adolescent outcomes after injury.