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

BMJ Qual Saf. 2015 Nov;24(11):709-17. doi: 10.1136/bmjqs-2014-003713. Epub 2015 Jul 16.

Abstract

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.

Keywords: Checklists; Emergency department; Paediatrics; Quality improvement.

MeSH terms

  • Checklist*
  • Child
  • Emergency Medicine
  • Emergency Service, Hospital
  • Humans
  • Incidence
  • Intubation, Intratracheal / adverse effects
  • Intubation, Intratracheal / methods*
  • Intubation, Intratracheal / standards*
  • Oximetry / methods
  • Oxyhemoglobins* / analysis
  • Oxyhemoglobins* / metabolism
  • Pediatrics
  • Quality Improvement
  • Treatment Outcome
  • Video Recording

Substances

  • Oxyhemoglobins