• Benjamin T Kerrey, Matthew R Mittiga, Andrea S Rinderknecht, Kartik R Varadarajan, Jenna R Dyas, Gary Lee Geis, Joseph W Luria, Mary E Frey, Tamara E Jablonski, and Srikant B Iyer.
• Division of Emergency Medicine and the Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
• BMJ Qual Saf. 2015 Nov 1; 24 (11): 709-17.

ObjectivesRapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2<90%). This report describes a multidisciplinary initiative to improve the performance and safety of RSI in a paediatric ED.MethodsWe conducted a local improvement initiative in a high-volume academic paediatric ED. We simultaneously tested: (1) an RSI checklist, (2) a pilot/copilot model for checklist execution, (3) the use of a video laryngoscope and (4) the restriction of laryngoscopy to specific providers. Data were collected primarily by video review during the testing period and the historical period (2009-2010, baseline). We generated statistical process control charts (G-charts) to measure change in the performance of six key processes, attempt failure and the occurrence of oxyhaemoglobin desaturation during RSI. We iteratively revised the four interventions through multiple plan-do-study-act cycles within the Model for Improvement.ResultsThere were 75 cases of RSI during the testing period (July 2012-September 2013). Special cause variation occurred on the G-charts for three of six key processes, attempt failure and desaturation, indicating significant improvement. The frequency of desaturation was 50% lower in the testing period than the historical (16% vs 33%). When all six key processes were performed, only 6% of patients experienced desaturation.ConclusionsFollowing the simultaneous introduction of four interventions in a paediatric ED, RSI was performed more reliably, successfully and safely.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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