• Sholeen Nett, Guillaume Emeriaud, J Dean Jarvis, Vicki Montgomery, Vinay M Nadkarni, Akira Nishisaki, and NEAR4KIDS Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network.
• 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.
• Pediatr Crit Care Me. 2014 May 1;15(4):306-13.

ObjectiveTracheal 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.DesignProspective observational cohort study.SettingFifteen PICUs in North America.SubjectsCritically ill pediatric patients requiring tracheal intubation.InterventionsNone.Measurement And Main ResultsTracheal 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.ConclusionsSubstantial 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.

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