Piloting a Premedication Algorithm to Standardize and Increase Rate of Premedication for Non-emergent Intubations in a Level IV Neonatal Intensive Care Unit

Purpose/Objectives: Pre-medicating for non-emergent neonatal endotracheal intubations reduces pain and risk of airway trauma, lessens number of attempts and duration to intubate. Decreased duration to intubate and decreased number of intubation attempts are associated with a decreased risk of intraventricular hemorrhage and improved neurodevelopmental outcomes. Routine premedication for non-emergent neonatal intubations is recommended by the American Academy of Pediatrics. However there is significant variation in practice and most units do not have protocols or guidelines for standardized use of premedications, including our own level IV neonatal intensive care unit (NICU). The objectives of this quality improvement project was to standardize and increase the use of pre-medications to 80% by 1 year for non-emergent endotracheal intubations in our NICU by developing and implementing an algorithm for pre-medication.

Design/Methods: Chart review was done on non-emergent neonatal intubations between January 2019 to July 2020, including demographics, use of premedications, associated adverse events and pain scores. Additionally, a survey was sent to neonatology fellows and attendings in our unit to identify perceived barriers to pre-medicating. An algorithm (Figure 1) was then developed based on current literature and guidelines and an order set was created in the electronic medical system. Each 4-month test cycle started with 1) education sessions with providers including physicians, nursing, pharmacy and respiratory therapy, followed by 2) implementation of the algorithm in clinical practice, and at the end of the cycle, 3) the rate of pre-medication, barriers to pre-medicating, adverse events and pain scores were evaluated. We anticipated a 20% increase in the rate of use of standardized premedication at the end of each cycle.

Results: The pre-intervention pre-medication rate in our unit was 12%, with only fentanyl use. The barriers to pre-medication were hesitancy in using opioids and paralytics, knowledge gap on the risks and benefits of pre-medicating and how to pre-medicate and accessibility of recommended drugs at our center.

Our pilot cycle from February 2021 to May 2021 captured 20 episodes of non-emergent intubations. At the end of the cycle, the overall pre-medication rate had increased to 37.5%. 19% of eligible intubations were compliant with the algorithm. In the pre-medicated group, there were more successful first intubation attempts (0.5% vs 0.14%), lesser intubation attempts (1.4 vs. 1.67), and less post-intubation vital sign abnormalities (0% vs. 29%). The major identified barrier to pre-medicating was hesitancy in using opioids and paralytics.

Conclusion/Discussion: With the implementation of a pre-medication algorithm, we achieved a higher overall rate of pre-medication from 12% to 37.5%. However, compliance to algorithm was only 19%. The major barrier to standardized pre-medication was hesitancy in opioid and paralytic use, representing a persistent knowledge gap. Interventions in following cycles will include an emphasis on education of staff.