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Pediatr Qual Saf. 2019 Nov 19;4(6):e230. doi: 10.1097/pq9.0000000000000230. eCollection 2019 Nov-Dec.

Breathing Easier: Decreasing Tracheal Intubation-associated Adverse Events in the Pediatric ED and Urgent Care.

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Department of Pediatric Emergency Medicine, University of Colorado, Aurora, CO, USA.


Tracheal intubation is a high-risk procedure in the pediatric emergency department (PED) and pediatric urgent care (PUC) settings. We aimed to develop an airway safety intervention to decrease severe tracheal intubation-associated adverse events (TIAEs) by decreasing process variation.


After gathering baseline data on TIAE, an interdisciplinary team underwent a mini-Delphi process to identify key drivers for decreasing severe TIAE rates. We launched a 4-part airway safety bundle that included: (1) color-coded weight-based equipment chart, (2) visual schematic of airway equipment, (3) recommended medication dosing, and (4) safety checklist across a single, tertiary PED and 5 satellite community PUCs/PEDs. Multiple plan-do-study-act cycles were undertaken, and results were monitored using statistical process control charts. Charts were restaged when special cause variation was achieved. This study aimed to decrease the severe TIAE rate from a baseline of 23% in the tertiary site and 25% in the community sites to <15% within 12 months and to sustain these outcomes for 6 months.


During the study period, we noted decreased rates of severe TIAE in both the PED and PUC setting during the intervention period, and we have sustained this improvement for more than 6 months in all sites with no associated change in balancing measures.


Implementation of an airway safety bundle over a wide geographic area and among personnel with variable levels of training is possible and has the potential to decrease severe TIAE across multiple clinical settings.

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