389 - Implementing a Premedication Protocol for Non-emergent Neonatal Intubations: A Quality Improvement Initiative

Poster Number: 389
Publication Number: 389.435

April W. Tan, Holtz Children's Hospital Jackson Memorial Hospital, Miami, FL, United States; Chanique T. James, Jackson Memorial Hospital/University of Miami, Miami, FL, United States; Alejandra Mac Quhae, Holtz Children's Hospital Jackson Memorial Hospital, Doral, FL, United States; Marta Galarza, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States

Background: Premedicating for non-emergent neonatal tracheal intubations reduces pain and risk of airway trauma, decreases number of attempts and duration to intubate. Decreased intubation attempts is associated with lower risk of intraventricular hemorrhage and improved neurodevelopmental outcomes. The American Academy of Pediatrics recommends premedicating but our NICU had a low premedication rate of 12% with fentanyl use only.

Objective: To improve the rate of premedication for non-emergent intubations in all neonates admitted to our NICU from 12% to 80% in 1 year.

Design/Methods: The Plan-Do-Study-Act (PDSA) model was used. A bundle of interventions were implemented, including an evidence-based premedication protocol, creating an order set in the electronic medical chart, availability of drugs in-unit and multidisciplinary staff education (Physicians, nurses, pharmacists and respiratory therapists). Outcome measures were premedication rate, time taken to intubate, number of attempts and intubation-related events (IRE) such as bradycardia and desaturations. Balancing measures included frequency of chest wall rigidity. A run chart and departmental meetings were used to monitor progress and troubleshoot problems.

Results: We captured 25 episodes of non-emergent intubations in our pilot cycle (Feb to July 2021) and 28 episodes in PDSA Cycle 2 (Aug to Nov 2021). Premedication rate increased from 12% to 32% at the end of our pilot cycle. Due to limited evidence for benefit and the discomfort of providers with premedicating with vagolytics and paralytics, the protocol was simplified to partially premedicate with fentanyl only in Cycle 2. The overall premedication rate at the end of Cycle 2 was 75%. Intubations premedicated with fentanyl ± atropine were faster (20.5 vs. 36.8 seconds) but there was no difference in number of attempts, first-attempt success rate, or frequency of IRE. The use of atropine significantly decreased frequency of intubation-related bradycardia (0 vs 24%). There were no episodes of chest rigidity.Conclusion(s): We achieved an increased premedication rate of over 60% that was sustained for at least 5 months with the implementation of a premedication protocol. Protocol simplification significantly improved our premedication rate. The use of fentanyl ± atropine was associated with faster intubations but did not improve number of attempts or first-attempt success rate. Atropine use significantly decreased frequency of bradycardia during intubations. Our next steps will focus on provider education, optimizing our premedication regimen and sustaining the progress of our premedication rate.
Run chart of quality improvement process from February to November 2021