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Based on review of medical records, policy and procedures, and interviews with staff, it was determined that appropriately sized equipment for use with a laryngoscope (device used to visualize the windpipe) was not readily available for one patient (P) (P#1) of three sampled patients. On 10/7/24 at 8:09 p.m., P#1, a pediatric patient experienced cardiopulmonary arrest while at the facility. Other means of intubation (insertion of a flexible plastic tube into the trachea to maintain an open airway)were readily available and attempted.

Findings included:

A review of P#1's medical record " ED Care Timeline," revealed that P#1 arrived in the facility's Emergency Department (ED) on 10/7/24 at 7:16 p.m. with the complaint of an allergic reaction.
Continued review of the record revealed that at 7:30 p.m., Decadron (used to reduce inflammation) was given intramuscularly by injection (IM). At 7:39 p.m., Benadryl (antihistamine used to treat allergic reaactions) was given IM. At 7:40 p.m., Epinephrine (used to treat severe allergic reactions) was given IM.
Continued review of the "ED timeline" revealed that at 8:09 p.m., a code (term used when a patient requires resuscitation) was started that included cardiopulmonary resuscitation (CPR) (emergency procedure used for cardiac or respiratory arrest that includes chest compressions and artificial ventilation) and administration of medications.

A review of the "Medical Decision Making "revealed that the [MD] attempted to use the Glidescope (equipment that includes video to assist with intubation). The Glidescope was readjusted for visualization after the first attempt. On the next attempt and every time after, there was copious (large amount) vomit.
A further review of the "Medical Decision Making " revealed that P#1 was suctioned between bagging (method of giving rescue breaths in CPR) and became bradycardic (slow heart rate under 60 beats per minute) and hypoxic (low oxygen) despite proper bag valve mask ventilation (BVM) technique. MD HH noted that multiple attempts were made, but the airway was not visualized secondary to the copious vomit. A further review of the "Medical Decision Making " revealed that MD HH attempted a cricothyrotomy (a surgical procedure to establish an airway) three (3) times without improvement in the patient's condition. Following extensive suctioning and multiple failed attempts, the endotracheal tube (ETT) (a flexible tube placed in the trachea through the nose or mouth) was placed. There were bilateral (both sides) breath sounds, but P#1 did not regain a heart rate. There was difficulty keeping the ETT attached to the Ambu bag, and it was eventually removed after it was dislodged during compressions. The code lasted for over one (1) hour. Clinical Impression was documented as acute respiratory failure, cardiac arrest, respiratory arrest, and anaphylactic shock.

A review of the facility's policy titled "Pediatric Emergencies," Policy #17082248, last revised 11/2024, stated that in a cardiopulmonary arrest, "Pediatric Code Blue" measures will be taken according to PALS/ACLS (Pediatric Advanced Life Support) Guidelines and using the Broeslow Pediatric System. The Broeslow cart will be brought to the room while CPR is being initiated. The Pediatric Code Cart was prepared for pediatric patients of any age and is checked daily by nursing staff.

NICU/Pediatric Respiratory Airway equipment and supplies were in a tackle box on top of the Pedi-Code Cart and were maintained by the RT (Respiratory Therapist). Pediatric Ambu and mask set-up was maintained by the ED (Emergency Department).

A review of the facility's policy titled "Orotracheal Intubation and Rapid Sequence Induction (RSI)," Policy #11997280, last revised 5/2018, stated that the purpose of the policy was to establish guidelines for emergent orotracheal intubation via rapid sequence induction (RSI) and identify proper verification methods for endotracheal tube (ETT) placement throughout the facility.
Indication:
Unable to protect their airway.
Requires prolonged ventilatory support.
Incapable of sustaining adequate intrinsic ventilatory effort or oxygenation.
Procedure: Determine the need for intubation.
Utilize the acronym HEAVEN to determine the appropriate technique for intubation success:
" Hypoxemia
" Extremes of size
" Anatomic disruption/obstruction
" Vomit/blood/fluid in the airway
" Exsanguination
" Neck mobility
Assemble and test equipment to ensure proper functioning, including suction, oxygen, medications, and airways.
" Select the appropriate size tube and laryngoscope blade.
" Check cuff integrity.
" Verify stylet or Bougie inserts into the tube. Be sure that the stylet ends ½ inch proximal to the distal end of the tube.
If intubation was unsuccessful after an initial attempt:
" Ventilate the patient via BVM to maintain SaO2 > 93% and prepare for another attempt
(Consider changing equipment, position, or utilizing assistive devices such as the Bougie or maneuvers such as thyroid cartilage manipulation, BURP).
" Consider medicating the patient if required.
" Consider utilizing assistive devices.


A review of the facility's policy titled "Intubation Box Checks", Policy #17399052, last revised 1/2024, revealed the following:
1. The boxes would be checked every shift by the charge RN or designated RN for that unit to ensure the box was locked and the first item to expire had not already expired.

During an interview in the facility conference room on 4/14/25 at 12:05 p.m., with MD GG, he stated that he was familiar with the event that occurred with P#1. Internally, the facility did a drill down and reviewed what happened with the case. MD GG explained that MD HH had the Glidescope and Cricothyrotomy kits needed. MD GG stated that he believed the facility had everything needed for the standard of care.

An interview was conducted in the facility conference room on 4/14/25 at 1:30 p.m. with Risk Manager (RM) CC. A peer had been filling in for RM CC at the time of incident and most of the investigation was completed when she (RM CC) returned. The substitute RM interviewed all the nurses and Respiratory Therapists (RT) and completed a chart review. RM CC interviewed MD HH to get her viewpoint and sequence of events as well as conducted an inspection of the South Campus ED resuscitative equipment and inspected the room. The Broeslow Cart is a pediatric-specific cart, organized for staff to obtain items in pediatric emergencies. RM CC stated that P#1 was a "yellow" based on her weight. She looked at the Glidescope, interviewed the RT involved about the supplies and equipment. RM CC stated that there were a lot of things going on with the patient. The patient had a history of fainting spells and had been treated at the children's hospital. P#1's family member would not relinquish the patient to the team of the triage nurse, primary nurse, and MD HH. RM CC stated that once the staff got the patient from the family member, the patient had a very edematous (swollen) airway. P#1 also vomited 600 ml to 800 ml of thick food. The vomit was too thick to use a rigid suction tube; both the pediatric and adult tubes were too small to suction the food. An attempt to intubate P#1 with the Glidescope was unsuccessful. RM CC explained that the result of the initial internal review found that there was no deviation from "generally acceptable performance standards that resulted in severe harm or death." This was based on the facts that there were delays and difficulty getting P#1 away from the family membe; there was severe edema of the throat; and the child vomited during intubation attempts. RM CC explained that during the investigation, she determined that the Broeslow cart included a blade and handle that were incompatible. RM CC stated that the physician still had the Glidescope for intubation but could not get past the stricture from the edema. They should have been able to intubate the child with the Glidescope, and therefore, standard of care was followed.

An interview was conducted in the facility conference room on 4/14/25 at 2:30 p.m. with the Director of Quality and Safety Integration (DQS) BB. DQS BB stated that she participated in a debrief on the event with the Director of ED, CNO, Director of Respiratory, Lead Supervisor of RT, CMO, and RM.
DQS BB stated that deviations in the standards had not led to the death. It was determined that there was a knowledge deficiency that the Miller handle did not fit the blades in the Broeslow Cart. DQS BB stated that MD HH had the equipment to intubate with the Glidescope. The Miller handle and blades provide an alternative way to intubate; therefore, there was no deviation in the standard of care.

During an interview with Director of Respiratory Therapy (DRT) JJ in the facility conference room on 4/14/25 at 3:10 p.m., they explained that the respiratory therapist (RT) role during a code was to assist the physician with intubation. During the code with P#1, the RT gathered supplies that included an endotracheal tube, blades, stylet, suction catheter, tape, lubrication, gauze, and a nasogastric (NG) tube. The intubation kits are from the manufacturer and are pre-rolled in that packet. Each roll includes tubes based on the color-based system for weight. The handles are separate, and the ones they routinely use are disposable. DRT JJ explained that RT II, who was present during the event, stated that when the physician attempted to intubate with the Glidescope, the video screen was 'foggy' and an attempt to use the cricothyreotomy kit was made.

An interview was conducted in the facility meeting room on 4/15/25 with Registered Nurse (RN) KK. RN KK recalled that P#1 was crying, and inconsolable. P#1's family member said that the patient had been bitten by ants about 30 minutes before coming to the ED. P#1 had hives but could not see any ant bite marks. The family member said that before they came to the ED, they had gone out to eat, but did not say what she had eaten. P#1 was then brought to the ED because of the hives. RN KK explained to family member that this could be an allergic reaction, and that the physician will need to order medications. P#1's family member initially held onto the patient and after 5 minutes, the family member let P#1 go with RN KK for medication administration. Epinephrine, Benadryl and Decadron were given by injection to P#1. When P#1 started crying again, stridulous (making a shrill creaking sound) breath sounds were heard. The family member said that this had happened before when the patient turned blue and passed out.

RN KK recalled that when MD HH tried to explain to the parents that the situation was more than her (P#1) just being upset, it took about 10 minutes before the family member would allow P#1 to be taken by the staff. RN KK recalled that MD HH tried to explain to the family that interventions were needed before P#1 got worse and stopped breathing. RN KK stated she then took P#1 and placed her on the heart monitor. RN KK recalled drawing up medications and MD HH tried to intubate P#1. RN KK stated that when MD HH tried to attach the blade to the laryngoscope handle, she realized that the blade did not fit. RN KK stated that MD HH had a difficult time visualizing the airway with the Glidescope and then the patient started vomiting. Once intubated, vomitus was coming out of the breathing tube. RN KK stated that they kept suctioning, but there was so much vomit that P#1 could not get oxygen. RN KK stated that MD HH tried to do a cricothyrotomy on P#1 but that was unsuccessful and then MD HH tried intubating P#1 again. The staff worked on resuscitation until MD HH called the code.

A phone interview was conducted on 4/15/25 at 12:50 p.m. with the Respiratory Therapist (RT) II. RT II recalled P#1 and that they were called to the ED for possible intubation for a patient who had been bitten by ants. RT II stated that when she arrived, P#1 was crying and had good saturations.
RT II recalled that that the parents did not want the patient to be intubated. RT II explained that the physician asked the respiratory therapist to get everything set up for the intubation including supplies from the Broeslow cart and the Glidescope. RT II explained that MD HH started with a Glidescope and that MD HH thought it was cloudy and that it did not have the best visability. RT II explained that they also had the intubation kit from the Broeslow cart and that when MD HH tried to get the laryngoscope blade from the "Broeslow kit," to fit on the standard scope [Bright Scope] the laryngoscope blade from the pediatric intubation kit would not fit properly on the standard scope. RT II stated that MD HH tried to intubate a few times and was unable. RT II stated that it was her understanding that the MD HH could not visualize the cords to intubate P#1. RT II stated that MD HH then attempted a cricothytomy on P#1.