title: Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the national emergency airway registry for children*.
abstract: OBJECTIVE
  Tracheal intubation in PICUs is associated with adverse tracheal intubation-associated events. Patient, provider, and practice factors have been associated with tracheal intubation-associated events; however, site-level variance and the association of site-level characteristics on tracheal intubation-associated event outcomes are unknown. We hypothesize that site-level variance exists in the prevalence of tracheal intubation-associated events and that site characteristics may affect outcomes.
  
  
  METHODS
  Prospective observational cohort study.
  
  
  METHODS
  Fifteen PICUs in North America.
  
  
  METHODS
  Critically ill pediatric patients requiring tracheal intubation.
  
  
  METHODS
  None.
  
  
  RESULTS
  Tracheal intubation quality improvement data were collected in 15 PICUs from July 2010 to December 2011 using a National Emergency Airway Registry for Children with robust site-specific compliance. Tracheal intubation-associated events and severe tracheal intubation-associated events were explicitly defined a priori. We analyzed the association of site-level variance with tracheal intubation-associated events using univariate analysis and adjusted for previously identified patient- and provider-level risk factors. Analysis of 1,720 consecutive intubations revealed an overall prevalence of 20% tracheal intubation-associated events and 6.5% severe tracheal intubation-associated events, with considerable site variability ranging from 0% to 44% tracheal intubation-associated events and from 0% to 20% severe tracheal intubation-associated events. Larger PICU size (> 26 beds) was associated with fewer tracheal intubation-associated events (18% vs 23%, p = 0.006), but the presence of a fellowship program was not (20% vs 18%, p = 0.58). After adjusting for patient and provider characteristics, both PICU size and fellowship presence were not associated with tracheal intubation-associated events (p = 0.44 and p = 0.18, respectively). Presence of mixed ICU with cardiac surgery was independently associated with a higher prevalence of tracheal intubation-associated events (25% vs 15%; p < 0.001; adjusted odds ratio, 1.81; 95% CI, 1.29-2.53; p = 0.01). Substantial site-level variance was observed in medication use, which was not explained by patient characteristic differences.
  
  
  CONCLUSIONS
  Substantial site-level variance exists in tracheal intubation practice, tracheal intubation-associated events, and severe tracheal intubation-associated events. Neither PICU size nor fellowship training program explained site-level variance. Interventions to reduce tracheal intubation-associated event prevalence and severity will likely need to be contextualized to variability in individual ICUs patients, providers, and practice.
authors.affiliation: 1Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH. 2Department of Pediatrics, Sainte Justine Hospital, Montreal, QC, Canada. 3Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH. 4Department of Pediatrics, Division of Critical Care, Kosair Children's Hospital, University of Louisville, Louisville, KY. 5Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Sholeen
authors.initials: S
authors.lastname: Nett
authors.forename: Guillaume
authors.initials: G
authors.lastname: Emeriaud
authors.forename: J Dean
authors.initials: JD
authors.lastname: Jarvis
authors.forename: Vicki
authors.initials: V
authors.lastname: Montgomery
authors.forename: Vinay M
authors.initials: VM
authors.lastname: Nadkarni
authors.forename: Akira
authors.initials: A
authors.lastname: Nishisaki
mesh_terms: D002648:Child; D002675:Child, Preschool; D016638:Critical Illness; D005257:Fellowships and Scholarships; D006276:Health Facility Size; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D007223:Infant; D015278:Intensive Care Units, Pediatric / Q000458:organization & administration / Q000592:standards* / Q000706:statistics & numerical data*; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000379:methods; D009656:North America; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D058996:Quality Improvement; D012042:Registries
chemical_list: D006993:Hypnotics and Sedatives