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Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting
  1. Karen J O’Connell1,
  2. Sen Yang2,
  3. Megan Cheng3,
  4. Alexis B Sandler1,
  5. Niall H Cochrane1,
  6. JaeWon Yang3,
  7. Rachel B Webman3,
  8. Ivan Marsic2,
  9. Randall Burd3
  1. 1 Department of Emergency Medicine, Children’s National Health System, Washington, District of Columbia, USA
  2. 2 Department of Electrical and Computer Engineering, Rutgers University, Piscataway, New Jersey, USA
  3. 3 Division of Trauma and Burn Surgery, Children’s National Health System, Washington, District of Columbia, USA
  1. Correspondence to Karen J O’Connell, Department of Emergency Medicine, Children’s National Health System, Washington, DC 20010, USA; koconnel{at}


Background Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes.

Methods An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence.

Results We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99).

Conclusions Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.

  • clinical care

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  • Contributors All authors have contributed significantly to the creation, conduct, analysis and/or manuscript preparation involved in this study. Authors KO and RB were responsible for all aspects of this study and manuscript submission, including the study concept and design, study staff supervision, providing support and oversight to data acquisition, analysis and interpretation of the data, statistical expertise, administrative supervision of the study staff and drafting and critical revision of the manuscript for important intellectual content. RB was also responsible for obtaining funding in support of this study. Authors SY, MC, AS, NC, JY and RW were responsible for acquisition of data, analysis and interpretation of data and drafting and revisions of the manuscript. SY and IM also provided statistical expertise for this study.

  • Funding This work was supported in part by the National Library of Medicine of the National Institutes of Health (grant number R01LM011834).

  • Competing interests None declared.

  • Ethics approval This study was approved by the Institutional Review Board of Children’sResearch Institute, Children’s National Health System, Washington, DC, approval #Pro00006408.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.