Optimizing Post-intubation Sedation in the Pediatric Emergency Department

Purpose/Objectives: Pediatric emergency medicine airway management training emphasizes procedural skills with little emphasis on post-intubation sedation (PIS) care resulting in reactionary and variable PIS initiation between providers. Consequently, patients can experience considerable discomfort if inadequately sedated while paralyzed and unplanned extubations can occur as paralysis subsides. The limited data about PIS in the pediatric emergency setting is consistent with the adult literature, which shows about 50% of patients receive inadequate PIS. Our SMART aim is to reduce the time to initiating PIS from a mean of 42 minutes to less than 15 minutes in our pediatric emergency department by September 2021.

Design/Methods: A multidisciplinary team was formed in March 2020 to develop a key driver diagram (Fig. 1) and create a PIS protocol to standardize post-intubation care. Retrospective baseline data was obtained from December 2017 through March 2020 after which data was followed prospectively in consecutive groups of 3 intubations. Excluded patient encounters include those with cardiac arrest, hemodynamic instability, or penetrating head injury. Statistical process control charts were used to analyze data. Nelson rules were utilized to detect special cause variation. The primary outcome was the time from intubation to the administration of the first sedation medication. Level 1 reliability interventions surrounding protocol development, awareness, and education were employed from April-November 2020. Higher level reliability interventions including a protocol-driven order-set for PIS and adding the sedation plan in the pre-intubation checklist were implemented starting in December 2020.

Results: X-bar chart & S chart (S chart not shown) were used to analyze primary outcome data. The baseline data represents 138 intubations with a mean time to PIS of 42 minutes 14 seconds (Fig. 2). Following the creation of the workgroup, protocol development, and educational interventions, special cause variation was achieved resulting in a center-line shift to a mean time of 25 minutes 4 seconds. After the implementation of the protocol driven order set and the addition of the sedation plan to the pre-intubation checklist, special cause variation again shifted the center-line to a mean of 16 minutes.

Conclusion/Discussion: Development of a PIS protocol, education, and an order set were associated with a decrease in mean time to PIS. The level 1 reliability interventions likely increased team awareness of the importance of a standardized team-based approach to PIS initiation. The level 1 reliability interventions set a foundation so our team could utilize the higher reliability interventions to help us perform closer to our goal. For the future our team is planning to implement a system to have sedation medications prepared with rapid sequence intubation medications, which we hope will help us achieve our goal and help this become a sustained change.