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Eliminating the Preventable Occurrence of Right Mainstem Intubation in the Pediatric Trauma Patient: A Quality Performance Improvement (PI) Initiative
Tracy A. Larsen, RN, BSN, TCRN, Bradley S. Hernandez, MD, Elizabeth J. Roeber, MD, David J. Dries, MSE, MD, Sherry J. Willett. Regions Hospital Level I Adult and Level I Pediatric Trauma Center, St. Paul, Minnesota, USA.

Background: Right mainstem intubation is a preventable occurrence that can be associated with airway injury and barotrauma. A quality PI initiative was undertaken to eliminate the preventable occurrence of right mainstem intubation in pediatric trauma patients. Overall, objective of this performance measure is to achieve 0% right mainstem intubation.

Methods: In a Level I Adult and Pediatric Trauma Center, the Pediatric Major Trauma Resuscitation Policy was modified to improve documentation of pediatric airway management. Color-coded reference cards were attached to endotracheal tubes for pediatric trauma patients indicating the correct depth according to the Broselow resuscitation tape. Ongoing education was provided to emergency medicine staff, which performed intubation, to utilize available tools providing consistent and appropriate endotracheal tube depth. After intubation, chest x-ray was immediately obtained to determine tube insertion depth.

Results: A before-after review was conducted to evaluate the impact of protocol modification for pediatric intubation between January, 2009 and December, 2015. During this time, 1,948 pediatric trauma patients were admitted. During this 7 year period, only 94 pediatric trauma patients were intubated. Prior to implementation of PI initiative for pediatric intubation in October, 2014, right mainstem intubation occurred in 6 of 68 (8.8%) of intubated pediatric trauma patients. After implementation of the PI initiative, right mainstem intubation occurred in 1 of 26 (3.8%) of intubated pediatric trauma patients.

Conclusions: In a Level I Adult and Pediatric Trauma Center intubation is infrequent among children. Right mainstem intubation can be reduced among pediatric trauma patients with a focused PI program, ongoing education and prompt availability of intubation guides.

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