Site-Level Variation in Tracheal Intubation in the Pediatric Emergency Department

Objectives: – To describe site-level variation in the performance and outcomes of tracheal intubation (TI) in pediatric emergency departments (PEDs) using the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM). Methods: – A multicenter observational study of TI was performed between April 2018 and September 2023. TI data were obtained from the 16 PEDs contributing to the NEAR4PEM registry. Standard NEAR4PEM operational definitions were used. Site-level variation in TI performance and outcomes were reported using summary statistics and interquartile range (IQR), including first-attempt success (FAS) and adverse airway outcomes (AAOs). AAOs were defined as adverse tracheal intubation-associated events or oxygen desaturation (SpO2 <80%). Results: – A total of 1, 729 TIs were performed. Median annual site visits were 52, 500 (IQR: 39, 750, 64, 750). Median site admission rate was 14% (IQR: 11.7, 17). The proportion of infants was median 28.5% (IQR: 23, 32) and patients with a difficult airway feature was median 25% (IQR: 14, 37). A trainee performed a median 75% (IQR 71, 93) of first attempts. There was substantial variation among sites in TI practice (median, IQR): use of apneic oxygenation 38% (26, 53), use of a video laryngoscope 87% (67, 93), preinduction vagolytic use in infants 33% (5, 46), and TIs without paralysis 13% (10, 23). FAS per site was a median of 72% (IQR: 68, 76). The proportion of TIs with an AAO by site was median 24% (IQR: 16, 30). Conclusion: – Considerable variation exists in performance and outcomes of TI across the PEDs participating in NEAR4PEM. These findings will be used to inform future research and quality improvement efforts.