Publications

BACKGROUND: As part of a quality improvement initiative to reduce Emergency Department (ED) length of stay (LOS) for surgical consult patients, we e-mailed performance metrics to key stakeholders on a daily basis. ED and Surgery leadership used these daily metrics to identify and remedy contributing factors for increased ED LOS in patients who received surgical consults.

OBJECTIVE: To evaluate whether a quality improvement process driven by a daily performance metric e-mail would be associated with a change in ED LOS for surgical consult patients.

METHODS: Prospective before-after study looking at ED LOS for surgical consult patients after an e-mail intervention at a tertiary academic teaching hospital. All consecutive adult ED patients between July 1, 2010 and October 1, 2010 who received a general surgical consult were enrolled. The primary outcome measure was ED LOS, and secondary outcome measure was time to consultation.

RESULTS: There were 916 patients who had surgical consults placed during the study period; 459 patients presented before the intervention and 457 patients presented after the intervention. The median LOS decreased 54 min, from 463 min (interquartile range [IQR] 326-617) before the intervention to 409 min (IQR 294.5-528.5) after the intervention (p < 0.001). Time to consultation decreased 25 min, from a median of 160 min (IQR 87-265) to 135 min (IQR 70-239.5) (p = 0.002). There was no difference in age, severity, number of consults, or disposition. There was also no difference in median LOS for other consultation services or in previous years during the same time period.

CONCLUSIONS: ED LOS and time to consultation were decreased for surgical consult patients after initiation of daily performance metric e-mails.

OBJECTIVES: To characterize the landscape of process of care and safety outcomes for tracheal intubation across pediatric intensive care units

BACKGROUND: Procedural process of care and safety outcomes of tracheal intubation across pediatric intensive care units has not been described. We hypothesize that the novel National Emergency Airway Registry for Children registry is a feasible tool to capture tracheal intubation process of care and outcomes.

DESIGN: Prospective, descriptive.

SETTING: Fifteen academic PICUs in North America.

PATIENTS: Critically ill children requiring tracheal intubation in PICUs.

INTERVENTIONS: Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubation in 15 PICUs from July 2010 to December 2011 using the National Emergency Airway Registry for Children tool with explicit site-specific compliance plans and operational definitions including adverse tracheal intubation associated events.

MEASUREMENT AND MAIN RESULTS: One thousand seven hundred fifteen tracheal intubation encounters were reported (averaging 1/3.4 days, or 1/86 bed days). Ninety-eight percent of primary tracheal intubation were successful; 86% were successful with less than or equal to two attempts. First attempt was by pediatric residents in 23%, pediatric critical care fellows in 41%, and critical care attending physicians in 13%: first attempt success rate was 62%, first provider success rate was 79%. The first method was oral intubation in 1,659 (98%) and nasal in 55 (2%). Direct laryngoscopy was used in 96%. Ninety percent of tracheal intubation were with cuffed tracheal tubes. Adverse tracheal intubation associated events were reported in 20% of intubations (n = 372), with severe tracheal intubation associated events in 6% (n = 115). Esophageal intubation with immediate recognition was the most common tracheal intubation associated events (n = 167, 9%). History of difficult airway, diagnostic category, unstable hemodynamics, and resident provider as first airway provider were associated with occurrence of tracheal intubation associated events. Severe tracheal intubation associated events were associated with diagnostic category and pre-existing unstable hemodynamics. Elective tracheal intubation status was associated with fewer severe tracheal intubation associated events.

CONCLUSIONS: National Emergency Airway Registry for Children was feasible to characterize PICU tracheal intubation procedural process of care and safety outcomes. Self-reported adverse tracheal intubation associated events occurred frequently and were associated with patient, provider, and practice characteristics.

BACKGROUND: Effective airway management is the cornerstone of resuscitative efforts for any critically ill or injured patient. The role and safety of pediatric prehospital intubation is controversial, particularly after prior research has shown varying degrees of intubation success. We report a series of consecutive prehospital pediatric intubations performed by air-transport providers.

METHODS: We retrospectively reviewed intubation flight records from an 89-rotorcraft, multistate emergency flight service during the time period from January 1, 2007, to December 31, 2009. All patients younger than 15 years were included in our analysis. We characterized patient, flight, and operator demographics; intubation methods; success rates; rescue techniques; and adverse events with descriptive statistics. We report proportions with 95% confidence intervals and differences between groups with Fisher exact and χ tests; P < 0.05 was considered significant.

RESULTS: Two hundred sixty pediatric intubations were performed consisting of 88 medical (33.8%) and 172 trauma (66.2%) cases; 98.8% (n = 257) underwent an orotracheal intubation attempt as the first method. First-pass intubation success was 78.6% (n = 202), and intubation was ultimately successful in 95.7% (n = 246) of cases. Medical and trauma intubations had similar success rates (98% vs 95%, Fisher exact test P = 0.3412). There was no difference in intubation success between age groups (χ = 0.26, P = 0.88). Three patients were managed primarily with an extraglottic device. Rescue techniques were used in 11 encounters (4.2%), all of which were successful. Cricothyrotomy was performed twice, both successful.

CONCLUSIONS: Prehospital pediatric intubation performed by air-transport providers, using rapid sequence intubation protocols, is highly successful. This effect on patient outcome requires further study.

BACKGROUND: Tracheal intubation is an important intervention to stabilize critically ill and injured children. Provider training level has been associated with procedural safety and outcomes in the neonatal intensive care settings. We hypothesized that tracheal intubation success and adverse tracheal intubation-associated events are correlated with provider training level in the PICU.

METHODS: A prospective multicenter observational cohort study was performed across 15 PICUs to evaluate tracheal intubation between July 2010 to December 2011. All data were collected by using a standard National Emergency Airway Registry for Children reporting system endorsed as a Quality Improvement project of the Pediatric Acute Lung Injury and Sepsis Investigator network. Outcome measures included first attempt success, overall success, and adverse tracheal intubation-associated events.

RESULTS: Reported were 1265 primary oral intubation encounters by pediatric providers. First and overall attempt success were residents (37%, 51%), fellows (70%, 89%), and attending physicians (72%, 94%). After adjustment for relevant patient factors, fellow provider was associated with a higher rate of first attempt success (odds ratio [OR], 4.29; 95% confidence interval [CI], 3.24-5.68) and overall success (OR, 9.27; 95% CI, 6.56-13.1) compared with residents. Fellow (versus resident) as first airway provider was associated with fewer tracheal intubation associated events (OR, 0.42; 95% CI, 0.31-0.57).

CONCLUSIONS: Across a broad spectrum of PICUs, resident provider tracheal intubation success is low and adverse associated events are high, compared with fellows. More intensive pediatric resident procedural training is necessary before "live" tracheal intubations in the intensive care setting.

BACKGROUND: Although the number of elderly increases disproportionately throughout the industrialised nations and intubation-related cardiovascular compromise is associated with hospital mortality, no emergency medicine literature has reported the direction and magnitude of effect of advanced age on post-intubation hypotension. We seek to determine whether advanced age is associated with an increased rate of hypotension at airway management in emergency departments (EDs).

METHODS: We conducted an analysis of a multi-centre prospective observational study of 13 Japanese EDs from April 2010 to March 2012. Inclusion criteria were all adult non-cardiac-arrest patients who underwent emergency intubation. We excluded patients in whom airway management was performed for shock or status asthmaticus as the principal indication. Patients were divided into two groups defined a priori: age ≥ 65 years old (elderly group) and age < 65 years old (younger group). The primary outcome measure was post-intubation hypotension in the ED.

RESULTS: During the 24-month period, 4,043 subjects required emergency airway management at 13 EDs. Among these, the database recorded 3,872 intubations (capture rate 96%). Of 1,903 eligible patients, 975 patients were age ≥ 65 years (51%) and 928 patients were age < 65 years (49%). The elderly group had a significantly higher rate of post-intubation hypotension compared with the younger group [3% vs. 1%; unadjusted OR 2.7 (95% CI, 1.3-5.6); P = 0.005]. In a model controlling for potential confounders (sex, principal indication, method, medication used to intubate, multiple intubation attempts), advanced age had an adjusted OR for post-intubation hypotension of 2.6 (95% CI, 1.3-5.6; P = 0.01).

CONCLUSIONS: In this large multi-centre study of ED patients who underwent emergent airway management, we found that elderly patients have a significantly higher risk of post-intubation hypotension. These data provide implications for the education and practice of ED airway management that may lead to better clinical outcomes and improved patient safety.

OBJECTIVES: There is little information on geriatric emergency airway management. We sought to describe intubation practices and outcomes for emergency department (ED) geriatric and younger patients in Japan.

METHOD: We formed the Japanese Emergency Airway Network, a consortium of 11 medical centers, and prospectively collected data on ED intubations between 2010 and 2011. All patients 18 years or older who underwent emergent airway management were included in our study. Patients were divided to into 2 groups: 18 to 64-year olds and 65 years or older. We present descriptive data as proportions with 95% confidence intervals (CI).

RESULTS: The database recorded 3277 patients (capture rate 96%), and 3178 met the inclusion criteria. Of 3178 patients, 1844 (58%) were 65 years or older, 1334 (42%) were 18 to 64 years old, 809 (25%) were 80 years or older, and 407 (50%) of them were in the state of cardiac arrest. The geriatric group, compared to the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference 7%; 95% CI 4%-10%;) and in 2 attempts (90% vs 88%; difference 3%; 95% CI 1%-5%) or less. There was no significant difference in the adverse event rates by age group (difference 0%; 95% CI -2% to 3%).

CONCLUSION: In our multicenter study involving a large geriatric population, we found that geriatric patients were intubated with a higher success rate, compared to younger patients. These data provide implications for the geriatric ED airway practice that may lead to better patient-centered emergency care.

OBJECTIVE: This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications.

METHODS: A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed.

RESULTS: The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs.

CONCLUSION: The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy.

BACKGROUND: The recent availability of low-cost tablet computers can facilitate bedside information retrieval by clinicians.

OBJECTIVE: To evaluate the effect of physician tablet use in the Emergency Department.

DESIGN: Prospective cohort study comparing physician workstation usage with and without a tablet.

SETTING: 55,000 visits/year Level 1 Emergency Department at a tertiary academic teaching hospital.

PARTICIPANTS: 13 emergency physicians (7 Attendings, 4 EM3s, and 2 EM1s) worked a total of 168 scheduled shifts (130 without and 38 with tablets) during the study period.

INTERVENTION: Physician use of a tablet computer while delivering direct patient care in the Emergency Department.

MAIN OUTCOME MEASURES: The primary outcome measure was the time spent using the Emergency Department Information System (EDIS) at a computer workstation per shift. The secondary outcome measure was the number of EDIS logins at a computer workstation per shift.

RESULTS: Clinician use of a tablet was associated with a 38min (17-59) decrease in time spent per shift using the EDIS at a computer workstation (p<0.001) after adjusting for clinical role, location, and shift length. The number of logins was also associated with a 5-login (2.2-7.9) decrease per shift (p<0.001) after adjusting for other covariates.

CONCLUSION: Clinical use of a tablet computer was associated with a reduction in the number of times physicians logged into a computer workstation and a reduction in the amount of time they spent there using the EDIS. The presumed benefit is that decreasing time at a computer workstation increases physician availability at the bedside. However, this association will require further investigation.

INTRODUCTION: Mobile health (mHealth) technology can play a critical role in improving disaster victim tracking, triage, patient care, facility management, and theater-wide decision-making.

PROBLEM: To date, no disaster mHealth application provides responders with adequate capabilities to function in an austere environment.

METHODS: The Operational Medicine Institute (OMI) conducted a qualitative trial of a modified version of the off-the-shelf application iChart at the Fond Parisien Disaster Rescue Camp during the large-scale response to the January 12, 2010 earthquake in Haiti.

RESULTS: The iChart mHealth system created a patient log of 617 unique entries used by on-the-ground medical providers and field hospital administrators to facilitate provider triage, improve provider handoffs, and track vulnerable populations such as unaccompanied minors, pregnant women, traumatic orthopedic injuries and specified infectious diseases.

CONCLUSION: The trial demonstrated that even a non-disaster specific application with significant programmatic limitations was an improvement over existing patient tracking and facility management systems. A unified electronic medical record and patient tracking system would add significant value to first responder capabilities in the disaster response setting.