401 - Breathe Easier: A Standardized Intubation Checklist Reduces Hypoxia in Pediatric Emergency Intubations

Publication Number: 4393.401

Meredith Montgomery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Barron Frazier, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Kurt A. Smith, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Elizabeth Simonds, Vanderbilt University Medical Center, Nashville, TN, United States; Evie K. Cannon, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Justin Davis, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Kristina A. Betters, Vanderbilt University School of Medicine, Nashville, TN, United States; Donald H. Arnold, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States

Background: Endotracheal intubation (ETI) is a high-risk, low-frequency procedure performed in pediatric emergency departments (PEDs) where adverse events are common. To mitigate risk, our department implemented a standardized intubation checklist to improve performance, consistent with prior studies in adult populations.

Objective: To examine whether use of a standardized intubation checklist was associated with fewer complications during pediatric ETI and to evaluate the impact of procedural and provider factors on outcomes.

Design/Methods: We conducted a retrospective study of all PED ETIs from January 2016 – November 2020. Children actively receiving CPR during intubation were excluded. After checklist implementation in May 2018, patients were divided into pre- and post-checklist groups. Electronic health records were reviewed for patient, procedural, and outcome data. The primary outcome was any complication; the secondary outcome was hypoxia (SpO2 < 90%). Multivariable logistic regression estimated adjusted odds ratios (aORs) for outcomes, adjusting for relevant covariates (Table 1).

Results: Of 393 patients, 180 patients were intubated pre-checklist and 213 post-checklist. Among 243 cases with documented training levels, 44% were intubated by residents, 38% by fellows, and 18% by attendings. First-attempt success occurred in 269 (71%) cases. Post-checklist implementation was associated with decreased odds of hypoxia (aOR 0.34, 95% CI 0.14–0.84) but no reduction in overall complications (aOR 0.72, 95% CI 0.32–1.70). Multiple attempts were associated with increased odds of complications (aOR 1.78, 95% CI 1.10–2.87). Increased training level was associated with higher odds of both complications (aOR 4.75, CI 2.70-8.38) and hypoxia (aOR 4.54, 95% CI 2.49–8.30). Only nine intubations of 243 (4%) involved more than one provider.

Conclusion(s): Checklist implementation was associated with reduced peri-procedural hypoxia during pediatric ETI. Complication rates increased with higher provider training level. Because only nine intubations (4%) involved more than one provider, this pattern likely reflects greater case complexity or fewer procedural repetitions among senior trainees rather than escalation to a more experienced provider after failed attempts. Sustained checklist use and continued procedural training may improve airway safety and maintain skills over time.

Table 1. Multivariable logistic regression models of primary and secondary outcomes and relevant covariates in 393 children undergoing endotracheal intubation before and after implementation of a standardized pre-procedure checklist
Table 1.jpegAbbreviations: aOR, adjusted odds ratio; 95% CI, 95% confidence interval