TOP 29 - Optimization of Post-Intubation Sedation in the Pediatric Emergency Department: A Quality Improvement Project

Publication Number: 4731.TOP 29

Andrea Castillo, NewYork-Presbyterian Komansky Children’s Hospital, new York, NY, United States; Alexander Stephan, Weill Cornell Medicine, New York, NY, United States; Kevin Ching, Weill Cornell Medicine, New York, NY, United States; Robert A. Finkelstein, NewYork Presyterian Hospital/Weill Cornell Medicine, Hartsdale, NY, United States; Michael J. Alfonzo, Weill Cornell Medicine, New York, NY, United States; Vivian Kum, Weill Cornell Medicine, New York, NY, United States; Elena Mendez-Rico, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Snezana Osorio, Weill Cornell Medicine, New York, NY, United States; Nicole Gerber, NewYork Presbyterian - Weill Cornell Medicine, New York, NY, United States

Background: Post-intubation sedation (PIS) is vital in pediatric emergency care to maintain comfort, safety, and stability after airway management. Delayed or inadequate sedation can cause agitation, awareness during paralysis, and unplanned extubation. Locally, only 60% of pediatric emergency department (PED) intubations received PIS, with a 16-minute average delay and inconsistent agent use-revealing a significant practice gap.

Objective: To increase the proportion of patients initiated on the first PIS medication in the PED from 60.0% to 95.0% and to decrease the mean time to first sedation medication dose from 16 minutes to less than 10 minutes by November 2025.

Design/Methods: This ongoing observational Quality Improvement (QI) study includes planned sequential interventions in the PED of an academic tertiary care center and received IRB exemption. A resident-led interdisciplinary team, including trainees, attendings, pharmacy, and a QI specialist, created a Key Driver Diagram and designed the family of measures: percentage of patients initiated on PIS, time to first sedation medication administration in minutes, and provider's satisfaction with the PIS protocol (outcome); order set use, time of first sedation medication order entry, and PIS protocol adherence (%, process); and no increase in adverse events from under-sedation (balancing). We derived interventions from the tertiary drivers (Figure 1), creation of a standardized PIS protocol (Figure 2), design of an electronic medical record order set, and visual aids (Figure 3). Data are collected via chart review, analyzed using run charts (initially) and SPC chart (>12 data points). Run chart rules and Association for Process Improvement (API) rules will be applied to detect signal of change and special cause analysis, respectively. Surveys will be summarized descriptively. Univariate analysis will explore factors linked to care variation. Data will be stratified by race, ethnicity and language to detect factors associated with disparities in patient care.

Figure 1: Key Driver Diagram


Figure 2: Post-Intubation Sedation Protocol


Figure 3: Visual Aid and Checklist