• Katherine Finn Davis, Natalie Napolitano, Simon Li, Hayley Buffman, Kyle Rehder, Matthew Pinto, Sholeen Nett, J Dean Jarvis, Pradip Kamat, Ronald C Sanders, David A Turner, Janice E Sullivan, Kris Bysani, Anthony Lee, Margaret Parker, Michelle Adu-Darko, John Giuliano, Katherine Biagas, Vinay Nadkarni, Akira Nishisaki, and National Airway Emergency for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network.
• 1University of Hawai'i at Mānoa, School of Nursing and Dental Hygiene, Honolulu, HI. 2Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA. 3Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital, Valhalla, NY. 4Department of Pediatrics, New York Medical College, Valhalla, NY. 5Center for Simulation, Advanced Education and Innovation, Children's Hospital of Philadelphia, Philadelphia, PA. 6Department of Pediatrics, Division of Critical Care, Duke Children's Hospital, Durham, NC. 7Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH. 8Department of Pediatrics, Emory University School of Medicine, Children's Hospital of Atlanta, Atlanta, GA. 9Department of Pediatrics, Section of Pediatric Critical Care, UAMS/Arkansas Children's Hospital, Little Rock, AR. 10Department of Pediatrics, Division of Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY. 11Pediatric Critical Care Medicine, Medical City Children's Hospital, Dallas, TX. 12Nationwide Children's Hospital, Columbus, OH. 13Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children's Hospital, Stony Brook, NY. 14Pediatric Critical Care Medicine, The University of Virginia Health System Children's Hospital, Charlottesville, VA. 15Yale Pediatric Critical Care Medicine, Yale-New Haven Children's Hospital, New Haven, CT. 16Department of Pediatrics, Columbia University Medical Center, New York, NY. 17Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
• Pediatr Crit Care Me. 2017 Oct 1; 18 (10): 965-972.

ObjectivesTo describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders.DesignMixed methods.SettingThirteen PICUs of the National Emergency Airway Registry for Children network.InterventionRemote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks.Measurements And Main ResultsBundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182-781). Five sites were early (median, 153 d; interquartile range, 146-267) and eight sites were late adopters (median, 783 d; interquartile range, 773-845). Focus groups identified common "promoter" themes-interdisciplinary approach, influential champions, and quality improvement bundle customization-and "barrier" themes-time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention.ConclusionsImplementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

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