title: Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department.
abstract: OBJECTIVE
  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.
authors.affiliation: Division of Emergency Medicine and the Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Benjamin T
authors.initials: BT
authors.lastname: Kerrey
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Mittiga
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Andrea S
authors.initials: AS
authors.lastname: Rinderknecht
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Kartik R
authors.initials: KR
authors.lastname: Varadarajan
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Jenna R
authors.initials: JR
authors.lastname: Dyas
authors.affiliation: Division of Emergency Medicine and the Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Gary Lee
authors.initials: GL
authors.lastname: Geis
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Luria
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Frey
authors.affiliation: Department of Emergency Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Tamara E
authors.initials: TE
authors.lastname: Jablonski
authors.affiliation: The Division of Emergency Medicine and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
authors.forename: Srikant B
authors.initials: SB
authors.lastname: Iyer
mesh_terms: D057189:Checklist; D002648:Child; D004635:Emergency Medicine; D004636:Emergency Service, Hospital; D006801:Humans; D015994:Incidence; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods* / Q000592:standards*; D010092:Oximetry / Q000379:methods; D010108:Oxyhemoglobins / Q000032:analysis / Q000378:metabolism; D010372:Pediatrics; D058996:Quality Improvement; D016896:Treatment Outcome; D014741:Video Recording
chemical_list: D010108:Oxyhemoglobins
keywords: Checklists; Emergency department; Paediatrics; Quality improvement