(903) Institutional Variability in Pediatric Critical and Difficult Airways: A Multi-Institutional Survey

Introduction: High risk pediatric intubations, such as those with a difficult airway or risk of cardiac arrest, pose challenges for critical care providers. Lack of standardized definitions for critical and difficult airways (CA/DA) across hospitals increases variability in identifying patients and staffing resources to manage CA/DA. The objective of this survey was to describe institutional definitions and shared identification tools. We hypothesize that Anesthesiology-based PCCM divisions or those with pediatric anesthesia fellowships (“anesthesia” group institutions) are more likely to have CA/DA definitions and advanced airway teams (AATs).

Methods: Following a structured seven-step approach (Artino et al, 2014), we developed two complementary survey instruments to characterize CA/DA both at bedside clinician and ICU leadership levels. The individual survey was distributed to all members through the PALISI, PEDAL, and NEAR4KIDS lists. Individual survey items reported here include CA/DA paper-based and electronic health record (EHR)-based identification tools. The institutional survey was targeted to ICU medical directors and NEAR4KIDS site PIs. The institutional survey included formal CA/DA definitions and available resources including AATs. We compared groups using Chi-square test.

Results: We received 181 individual and 43 institutional responses. Most frequent EHR-based decision support included flag or “post-it” (49%), banner (35%), and historical note search (20%). Paper-based notification included bedside card (60.5%) and airway bundle checklist (47%). The anesthesia group comprised 31/43 (72%) of institutions. More institutions did not have formal definitions of DA (21/38, 55%) or CA (28/40, 70%) than did. The anesthesia group institution type was not associated with having DA/CA definitions (DA: 39% vs 42%, p=.86, CA: 29% vs 25%, p=.79). Most 29/43 (67%) institutions have an AAT, but this was no more likely among anesthesia group (65% vs 75%, p=.51). Of those institutions with AATs, 27 (93%) were available 24/7.

Conclusions: Wide variability exists in the identification of CA/DA with EHR and bedside notification. Standardized institutional CA/DA definition was often lacking. There were no differences in CA/DA definition and AAT presence between anesthesia vs. non-anesthesia group institutions.