(1375) Human Factors and Flow Disruptions During Tracheal Intubation

Introduction: Tracheal intubations (TIs) are critical procedures performed within complex systems. Flow disruptions (FDs) are a human factors engineering assessment that identifies multifactorial mismatches among provider skills, teamwork, communication, equipment, and environments. The objectives are to quantify and classify TI FDs and determine their association with patient outcomes. We hypothesized clinically important FDs would occur in more than 50% of TIs and be associated with adverse patient outcomes.

Methods: A prospective observational study in a medical-surgical US PICU (75 beds). 28 TIs (convenience sample) were directly observed from 12/2023 to 6/2024 by a single observer/rater trained by a FD expert. FDs were defined as deviations from the progression of care compromising safety and efficiency, and classified into 7 categories: communication, coordination, extraneous, equipment/technology/layout, resource, training, and technical. Severity was defined as mild (no impact), moderate (some impact), and severe (total cessation/disruption related to patient instability). Clinically important FDs were moderate or severe. Observation duration was from timeout to end of airway securement (4 phases; preparation, induction, instrumentation, securement). Clinical outcomes were documented in our TI database, using prospectively defined Adverse Airway Outcome (AAO: desaturation < 80% and/or any TI-associated events) as the primary outcome. FD counts were compared between TIs with vs. without AAO.

Results: 28 TIs were observed with 192 moderate/severe FDs. 96% (N=27) had at least one moderate/severe FD. A median of 5.5 (IQR=4.5-9) moderate/severe FDs were observed per TI. FDs occurred in all phases of TI: 32% in preparation, 35% in induction, 11% in instrumentation, and 21% in securement. The most frequent FD categories were equipment/technology/layout (25%), training (22%), and technical (20%). The 1 TI with an AAO had 8 moderate/severe FDs while TIs without AAOs (N=27) had a median of 5 moderate/severe FDs.

Conclusions: Clinically important (moderate/severe) FDs occurred in more than 50% of TIs (96%). The most common FDs were equipment/technology/layout, training, and technical. Data were insufficient to evaluate the association between FDs and adverse patient outcomes.