Emergency Endotracheal Intubation in a Pediatric Intensive Care Unit: A Quality Improvement Study

Abstract

Background: Emergency Endotracheal Intubation (EEI) is a high-risk procedure with complications such as hypoxemia and hypotension. Despite these risks, EEI is routinely performed in Pediatric Intensive Care Unit (PICUs), which are complex and hazard-prone environments. Suboptimal intubation can lead to adverse outcomes, including brain injury, cardiac arrest, and death. Quality improvement (QI) measures, including system changes and standardized protocols, have been shown to improve first-pass success rates and reduce adverse events. This study describes a QI project aimed at enhancing safety EEI. Objective: To improve the first pass success rate of emergency endotracheal intubation in children in the PICU and reduce procedure related adverse events through QI interventions. Method: The study was conducted in the PICU over three months. A multidisciplinary QI team was formed. Baseline data were collected from 50 intubations using a structured checklist. Root cause analysis was performed using fishbone methodology. Based on identified deficits, interventions were developed and tested through Plan-Do-Study-Act (PDSA) cycles. Post-Intervention data were collected using the same checklist. Interventions were accepted, rejected, or modified based on results. Intubation parameters were reassessed one year later to evaluate sustainability. Results: Following interventions, the first-pass success rate improved from 62% to 88% (p = 0.0004). Preoxygenation compliance increased from 3% to 88% (p = 0.00004). Equipment checks improved from 55% to 90% (p = 0.0005). Complications decreased from 38% to 12%, reflecting better patient safety. One year later, the improvements remained sustainable: first-pass success rate 79%, preoxygenation 75%, and equipment checks 89%. Conclusion: The first-pass success rate should be adopted as a standard quality metric for auditing intubation care. Mandatory simulation-based training for all staff is essential.