A Stepwise Approach to Improved Intubation Success Rates During Neonatal and Pediatric Interfacility Transport

Purpose/

Objectives: First attempt intubation success rates among critical care transport teams are highly variable. Multiple intubation attempts are associated with adverse outcomes. The Angel One Transport Team at Arkansas Children’s Hospital (ACH) initiated a series of interventions aimed at improving out-of-hospital intubation success rates. Video laryngoscopy was introduced in 2015. A rapid sequence medication protocol for non-emergent neonatal intubations was introduced in May, 2018. We hypothesized that the use of these interventions would improve first attempt intubation success rates.

Objective: Improve ACH transport team first attempt intubation success.

Design/Methods: The transport team intubation database was reviewed from January 2008 through May 18, 2021. Success rates were defined as the number of successful first attempt intubations divided by the total number of patients requiring intubation in each cohort. Patients were divided into 3 categories: Neonates weighing <1kg, neonates weighing >1kg, and non-neonatal (pediatric) patients, neonates being defined as patients.


Results:  Overall first attempt intubation success rates were statistically higher for pediatric patients (PP, 63.19%) and neonatal patients >1kg (NP>1, 55.44%) when compared to neonatal patients <1kg (NP <1, 40.40%): PP(N=182) vs NP < 1(N151), 22.79%diff (12.04%,32.82%), p<0.01; NP>1kg(N=487) vs. NP <1kg(N=151), 15.04%diff (5.92%,23.71%), p<0.01; PP(N=182) vs. NP>1(N=487), 7.75%diff (-0.67%,15.76%). Introduction of video laryngoscopy led to increased first attempt success in pediatric patients and neonatal patients >1kg: PP; 58.33% (pre,N=108) vs. 72.97% (post,N=74), 14.64%diff (0.47%,27.53%), p=0.04; NP>1; 47.52% (pre,N=242) vs. 64.08% (post,N=245), 16.56%diff (7.75%,25.02%), p<0.01. Introduction of a rapid sequence medication protocol for neonatal patients >1kg also led to improved first attempt intubation success: NP>1; 51.92% (pre,N=364) vs. 65.85% (post,N=123), 13.93%diff (3.81%,23.25%), p<0.01. Video laryngoscopy and the rapid sequence medication protocol were not used in neonatal patients <1kg.
Conclusion/

Discussion: The introduction of video laryngoscopy and use of a rapid sequence medication protocol resulted in a significant increase in first attempt intubation success for neonates >1kg and pediatric patients. First attempt success in neonates <1kg was lower than the other groups and did not improve over the study period. This is likely secondary to these patients requiring emergent intubation and being too small for the smallest video laryngoscopy blade. Further methods of intubation improvement should be investigated for this population, especially for very low birth weight premature neonates.