373 - Airway Safety Team- A Quality Improvement Initiative To Improve Neonatal Airway Safety

Poster Number: 373
Publication Number: 373.434

Hsiang-fen F. Su, Cedars- Sinai Medical Center, Tarzana, CA, United States; Lionel Newman, Cedars-Sinai Providence Tarzana Medical Center, Marietta, GA, United States; Timothy m. Berry, providence tarzana, camarillo, CA, United States; Camilla Kiswardy, Providence Cedars-Sinai Tarzana Medical Center, Valencia, CA, United States; Kennedy Toro, Providence Health Services, Tarzana, CA, United States; mary T. miller, Providence Cedars Sinai Tarzana Medical Center, Westlake Village, CA, United States; Michael Luu, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Roxanne Arcinue, Providence Cedars-Sinai Tarzana Medical Center, Tarzana, CA, United States

Background: Correct and secured endotracheal tube (ETT) placement is critical in providing the optimal respiratory support for infants on mechanical ventilation. Adjustment of ETT due to malposition can lead to hypoxic and bradycardic episodes and unplanned extubation (UPE).

Objective: The aims were: 1) to improve the percentage of babies who have the target ETT placement, defined as the ETT tip at T1-T3, on the first CXR after intubation by 10% in 24 months, therefore reducing the number of X-rays taken, and 2) to reduce the incidence of UPE (number of UPE/100 ventilator days) by 10% in 24 months.

Design/Methods: A multi-disciplinary “Airway Safety Team” was established, which was composed of neonatologists, respiratory therapists, nurses, radiology staff, developmental therapists, and data analysts. Aims, key driver diagram (Fig 1), and project charter were created. The following interventions were implemented: education of NICU staff about the standard methods to determine ETT insertional depth based on the Neonatal Resuscitation Program (NRP), updated NRP charts with new ETT depth reference in all delivery rooms, documentation of intubations with methods used and final insertion depth, bedside rounds discussion about ETT position and securing device, standardization of the securing device of ETT, revised UPE forms, weekly project poster board discussion, assistance of radiology technicians in proper positioning of patient for X-ray, and implementation of “Arms Within Reach” approach for all intubated patients.

Results: All NICU babies who were intubated were included. Our intervention period was from September 2019 to August 2021 (total of 83 babies, 96 intubation events), which was compared to our baseline period from January 2016 to August 2019 (total of 105 babies, 154 intubation events). There was >10% improvement from baseline on both aims. Target ETT position on the first CXR improved from 53% to 63% (21%) (Fig 2). UPE rate was reduced from 3.3 to 2.9 (12%) (Fig 3). During the last 6 months of the project, there was no UPE event despite the higher monthly ventilator days and number of patients, and the average monthly target ETT placement was 70%Conclusion(s): Standardization of neonatal airway management by a multi-disciplinary team approach can reduce the number of X-rays needed to confirm ETT position and reduce UPE events.
Fig 1: Key Driver Diagram
Fig 2: Percentage of ETT at the target position on the first CXR after intubation