Developing a Standardized Premedication Protocol to Improve Safety of Non-emergent Intubations in the Neonatal Intensive Care Unit

Purpose/Objectives: In 2010 the AAP recommended premedication use for all non-emergent intubations, yet there remains significant variation in this practice in our regional level IV NICU. We aimed to improve patient safety during non-emergent endotracheal intubation by implementing a standardized premedication protocol to decrease number of attempts and adverse events.

Design/Methods: Baseline data was collected in the 9-month period preceding protocol implementation. A multi-disciplinary workgroup developed protocol content utilizing evidence–based literature review with subsequent adaptation to local context. An educational video series was created to train bedside staff (RNs, RTs, providers) on the novel protocol. This included skills demonstration of medication administration and introduction to the role of the bedside recorder role (whose responsibility is to audit process, outcome and balancing measures). A pre-intubation checklist was also introduced to target interdisciplinary communication and clear role assignment for bedside staff. Differences between baseline and protocol cohort measures were compared using independent t test for continuous, non-normally distributed data and 𝜒2 for discrete non-normally distributed data for select variables.

Results: 97/206 (47%) of bedside staff viewed video content ahead of protocol launch. 189 patients met inclusion criteria and completed the protocol, with 81% audit form completion rate (153/189). Compared to the baseline cohort, a statistically significant decrease in average number of intubation attempts (2.2 ± 0.3 vs. 1.8 ± 0.3) (p=0.006) was observed. There was an increase in success rate on 1st intubation attempt across all provider types from a baseline of 62/158 (39%) to 110/189 (58%) with a notable improvement in rate of trainee success on 1st attempt from 1/40 ( <1%) to 28/63 (44%). The rate of non-severe adverse events (as % of overall adverse events) increased from a baseline of 48% to 55%. The rate of severe and rare events decreased from a baseline of 35% to 27%. Rate of tachycardia with atropine use was 10/189 (5%), however no baseline data is available for comparison to determine process change. There was no statistically significant change in rate of chest wall rigidity or number of infants unable extubate following surfactant. No infants decompensated awaiting medication.

Conclusion/Discussion: Developing a standardized premedication protocol has increased our unit's compliance with the standard of care. Furthermore, we have demonstrated a decrease in average number of intubation attempts and increased success rate on 1st intubation attempt with a notable improvement in trainee success. The relative rise in non-severe adverse events was anticipated given the introduction of a patient safety reporting system and the use of atropine to prevent vagal response. While not statistically significant, there is a trend towards decreased rates of severe adverse events, rare events and procedural events compared to the baseline data.