Improving the Safety of Rapid Sequence Intubation in a Pediatric Emergency Department
In a recent, video-based study of rapid sequence intubation (RSI) in our pediatric emergency department (PED), we reported a high frequency of oxyhemoglobin desaturation (33% of children, SpO2<90%). We hypothesized that implementation of a standardized bundle of interventions targeting modifiable aspects of the RSI process would reduce the risk of desaturation.
We performed a prospective study of desaturation during RSI in a high-volume PED. We designed an intervention bundle, targeting aspects of the RSI process which we theorized were associated with desaturation. The bundle consisted of: 1) a novel RSI checklist, 2) a physician responsible for checklist execution, 3) incorporation of a video-laryngoscope into the RSI process, and 4) restriction of laryngoscopy to specific providers (table). Training to improve laryngoscopy skill was not performed. Iterative improvements to the bundle were made during the intervention period. All patients undergoing RSI in our ED were eligible for the bundle. Data were collected from video-recordings of RSI. The main outcome was desaturation during RSI. To detect early changes after bundle implementation, we calculated the number of patients between patients with desaturation. We calculated relative risk (RR, 95% CI) of desaturation in the intervention versus baseline period.
There were 114 patients during the baseline period (April 2009-March 2010, 92% capture) and 48 during the intervention period (July 2012-March 2013, 100%). All bundle components were employed for 38 patients during the intervention period (79%); the checklist for 44 patients (92%). Statistical process control (g-chart) demonstrated special cause variation in the occurrence of desaturation during the intervention period (data point above upper control limit, figure). Desaturation decreased from 33% during the baseline period to 17% during the intervention period (RR 0.5, 95% CI 0.25,0.99; table). For children ≤2 years (highest risk in previous study), desaturation decreased from 54% to 27% (RR 0.49, 95% CI 0.25,0.98).
The implementation of an improvement bundle, without specific attention to laryngoscopy skill, was associated with a 50% reduction in the risk of desaturation for children undergoing RSI in a PED, including in the highest risk group.