P2.117: Implementing an Airway Checklist in a Mixed Cardiac and Medical Pediatric ICU: Challenges and Strategies

Purpose/Objectives: Airway management in the pediatric intensive care unit (PICU) is a high-risk procedure with potential for significant morbidity and mortality. Structured airway checklists have been shown to improve safety by standardizing pre-intubation preparation, optimizing team communication, and reducing adverse events. However, implementing such a checklist in each PICU presents unique challenges due to varying provider experience, patient physiology, and institutional culture. This quality improvement (QI) project aimed to develop and implement an airway checklist in a mixed cardiac and medical/surgical PICU at UC Davis Children’s Hospital, with a goal of achieving 80% compliance.

Design/Methods: A multiprofessional QI team—including pediatric intensivists and fellows, nurses, respiratory therapists, pharmacists, and nurse educators—was convened to develop a standardized pre-intubation checklist tailored to the unit’s patient population. The project followed the Model for Improvement framework with Plan-Do-Study-Act (PDSA) cycles to iteratively refine the checklist and implementation process. The primary outcome measure was compliance with a pre-intubation airway checklist for patients meeting inclusion criteria comprising of any of the following: Glascow Coma Scale < 12, tracheostomy status, planned sedation, positive pressure ventilation including non-invasive support, or HFNC support above the unit standard. Baseline and post-intervention data on pre-intubation preparation and adverse events—hypoxia, bradycardia, hypotension, multiple airway attempts, laryngospasm, and cardiac dysrhythmia or arrest—were collected via chart review and direct observation. Outcome data was monitored on run charts throughout the study period. Interventions are specified in Figure 1.

Results: Initial checklist use was inconsistent with completion varying between medical/surgical and cardiac populations. Compliance in the pediatric cardiac intensive care unit (PCICU) was easier to achieve and sustain. Within the PICU, Compliance positively correlated with the presence of QI team members on the unit. Over multiple PDSA cycles, targeted interventions aimed at embedding the checklist into provider workflows improved adherence. Combined PCICU and PICU implementation reached over 90% within 4 months. Key facilitators included nursing engagement, creation of a new admission workflow, and reinforcement during compliance tracking. Major barriers included provider resistance, logistical challenges, and time constraints. Safety data comparing adverse airway events before and after adoption of checklist did not show significant change but was difficult to interpret due to low incidence.

Conclusion/Discussion: Implementing an airway checklist in a mixed cardiac and medical/surgical PICU requires a tailored approach addressing the diverse needs of the specific unit. The differences in staffing and turnover between the two parts of the unit created differences in project compliance. While this project achieved the 80% compliance goal, achieving sustained compliance beyond the study period remains an ongoing challenge. Reinforcement and cultural change are essential for long-term sustainability. The outlined experience provides a roadmap for other institutions seeking to implement similar protocols in complex critical care environments.