Eliminating Preventable Harms During Pediatric Intubation
Akira Nishisaki, M.D., M.S.C.E.
Attending Physician, Critical Care Medicine, Children’s Hospital of Philadelphia
Co-Medical Director for Center for Simulation, Advanced Education and Innovation, Children’s Hospital of Philadelphia
Chair, Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
“I am thankful to the Agency for Healthcare Research and Quality for funding projects that focus on our vulnerable children so that their health can be improved through the quality of the care we provide for them.”
Respiratory failure is the leading cause of death in infants and children. For more than 25 years, Akira Nishisaki, M.D., M.S.C.E., a pediatric critical care physician in the Department of Anesthesiology and Critical Care Medicine at the Children’s Hospital of Philadelphia, has dedicated his career to improving the quality of care and outcomes for critically ill or injured children who are experiencing respiratory failure, which is caused by various conditions, including pneumonia, asthma attacks, injuries, or underlying diseases affecting the heart or nervous system.
With funding from AHRQ, Dr. Nishisaki, who is also a professor of clinical anesthesiology, critical care, and pediatrics at the University of Pennsylvania Perelman School of Medicine, has designed and implemented easily modifiable quality improvement processes for providers and practices to make pediatric airway management safer.
Dr. Nishisaki received his first AHRQ grant to improve safety during pediatric tracheal intubation, a procedure to help with breathing when the airway is blocked or damaged. Tracheal intubation is one of the most common procedures conducted in the pediatric intensive care unit (ICU). However, it is high risk and difficult—roughly one in five children who undergo the procedure face complications, including breathing issues, low blood pressure or, in extreme cases, cardiac arrest. These adverse events are influenced by patient, provider, and practice factors.
During this project, Dr. Nishisaki and his team developed the National Emergency Airway Registry for Children (NEAR4KIDS), a quality improvement database used across 16 pediatric ICUs that documents outcomes of tracheal intubations based on patient, provider, and practice factors. Its primary goal is to improve advanced airway management for critically ill children. Findings from NEAR4KIDS served as the foundation for the team’s future research to eliminate preventable harms during pediatric intubation.
Dr. Nishisaki’s second grant used data from the NEAR4KIDS registry to create the airway bundle checklist, a tool medical teams could easily use at the patient’s bedside. The checklist provides opportunities for pre-procedure assessment and planning, a procedure timeout, and a post-procedure huddle. The pre-procedure checklist helps teams cross-check for patient risk factors that could affect the airway, like the size of the mouth or neck, or increased risk of oxygen desaturation. The post-procedure huddle facilitates a debrief discussion, where clinical teams can develop plans for future procedures.
Dr. Nishisaki received a third AHRQ grant to focus on additional quality improvement interventions for procedures that occur during tracheal intubation. In the first intervention, the team attached a camera to the laryngoscope, the instrument that goes into the throat during intubation, to provide video views for coaching and supervision. The second intervention involved administering continuous oxygen to allow more time for clinicians to safely complete the intubation procedure. Both the video laryngoscope and apneic oxygenation interventions resulted in reductions in adverse events and continue to be used throughout the NEAR4KIDS network of pediatric ICUs.
Dr. Nishisaki received another AHRQ grant to determine how to improve bag mask ventilation, a critical skill used during tracheal intubation. Bag mask ventilation is performed in more than 95 percent of tracheal intubations; however, it is challenging to perform in critically ill children because of their health conditions and unique anatomy. This project showed the importance of a clinician’s ability to provide proper manual oxygen during pediatric tracheal intubation using a handheld bag mask and laid the groundwork for future quality improvement interventions to prevent low oxygen and high carbon dioxide during the procedure.
Dr. Nishisaki’s fifth and current grant, Smart Checklist Implementation for Pediatric Tracheal Intubations in the ICU-Multicenter Study: SMART PICU, aims to digitize the airway bundle checklist that was developed as a result of funding from his second AHRQ grant.
Dr. Nishisaki also serves as Chair of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network, which is the largest nonprofit pediatric ICU clinical research network. The NEAR4KIDS network is a subgroup of the PALISI network. Dr. Nishisaki accredits his successful track record and ability to lead the PALISI network to the support he has received from AHRQ funding. “Without funding from AHRQ, there would be no NEAR4KIDS database to document patient, provider, and practice factors or safety outcomes of tracheal intubation and no systematic evaluation of multicenter quality improvement intervention activities,” he said.
Principal Investigator: Akira Nishisaki, M.D., M.S.C.E.
Institutions: Children’s Hospital of Pennsylvania, University of Pennsylvania Perelman School of Medicine
Grantee Since: 2012
Type of Grant: Various
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