Texas Pediatric Society Electronic Poster Contest Improving Premedication for Non-emergent Intubation in the Neonatal Unit: A Quality Improvement Project Shweta Parmekar, MD, James M. Adams MD, Jennifer L. Placencia, PharmD, Gautham K. Suresh, MD, and Caraciolo J. Fernandes, MD Section of Neonatology, Baylor College of Medicine, Houston, Texas, Texas Children’s Hospital, Houston, Texas Abstract Results Neonatal intubation is one of the most common painful procedures performed in the unit and is associated with significant physiologic changes. A recent national survey showed only 43.6% of national fellowship programs use premedication. A review of current premedication rates in our NICU, a 174 bed quaternary care center, showed medications were being given in only 20% of all possible events and practice among choice of agents varied dramatically. Objective: We aimed to increase compliance of the use of recommended premedication, from 20% to 70% of all eligible intubations by June 2016. Design/Methods: We conducted a prospective, continuous,, quality improvement initiative. We collected retrospective data to determine baseline premedication rates and medication choices which showed an unacceptable premedication rate. The Model for Improvement and Plan Do Study Act (PDSA) cycles were used. The 2010 AAP Clinical Report recommendations and best practices were reviewed for our design. Outcome measures included airway injury, bradycardia, and number of attempts and our process measure was percent compliance. Balancing measures included chest wall rigidity and duration of event. Results: Percent compliance increased in response to the introduction of a standardized algorithmic approach (p=<0.001). Process changes such as improving medication accessibility and administration information reliably improved compliance. Atropine use significantly reduced events with bradycardia (p=0.0017). No significant changes were seen in the average number of attempts.  Conclusions: The use of a standardized algorithm and education can increase premedication compliance, consistency, and uniformity. Future work will target revision of recommendations, utilization of an order set, obtaining provider feedback, and our ability to sustain these improvements. Figure 3. Proportion of Patients Receiving Premedication for Non- emergent Neonatal Intubations Prior to Major Intervention of the QI. Introduction Endotracheal intubation is a painful procedure causing:1 Pain Bradycardia Systemic Hypertension Hypoxia Raised intracranial pressure Premedication is recommended to reduce these effects.2 However, surveys show that premedication is used only by 44% of fellowship programs. Only 24% of these programs have a written policy.3 Reasons why premedication is not done:4 Lack of familiarity with medications Fear of adverse effects Insufficient evidence for efficacy and safety Lack of consensus regarding an optimal regimen Retrospective review of intubation events beginning April 2015 in our NICU (which did not have a written policy) showed dramatic practice variation: Figure 4. Proportion of Patients Receiving Premedication for Non- emergent Neonatal Intubations Post Major Intervention of the QI. Table 1. Outcome and Balancing Measures. No premedication (n=49) Any premedication (n=83) p-value Number of attempts, mean + SD 2 ± 1 0.096 Event duration (min), mean + SD 16 ± 11 22 ± 14 0.017 Oropharyngeal bleeding, n (%) 3 (11) 0.157 Emesis, n (%) 2 (4) 2 (2) 1.000 Hypoxia (SpO2 ≤ 60%), n (%) 16 (38) 16 (19) 0.029 Chest wall rigidity, n (%) 3 (4) 0.294 Post-intubation severe hypercarbia (PCO2 > 80 mmHg), n (%) N/A 6 (14) Figure 1. Premedication Practice During Non-emergent Intubations in the Newborn Center prior to Study Interventions (April to August 2015). SPECIFIC AIM By June 30, 2016, to ensure that premedication is used prior to at least 70% of all non-emergent intubations in neonates with intravenous access. Table 2. Frequency of Bradycardia.   Without Atropine With Atropine p-value Heart Rate ≤ 60 n (%) 8 (24) 2 (3) 0.003 Description of Study Quality improvement initiative using the Model for Improvement, including Plan Do Study Act (PDSA) cycles Multidisciplinary team assembled and key drivers identified. Measures Premedication defined as use of one or more of the following medications pre-intubation: atropine, fentanyl, vecuronium. Process measure: use of premedication before eligible intubations. Outcome measures: number of attempts, duration of event, airway injury, bradycardia, and hypoxia. Balancing measures: chest wall rigidity, post-intubation severe hypercarbia, and duration of event. Changes The 2010 AAP Clinical Report on neonatal intubation, updated evidence review, and best practices were used to develop a unit-wide consensus and local practice guideline-atropine and fentanyl to be used in all cases, muscle relaxant based on clinician judgment. Conclusions A consensus-based unit guideline was successfully developed and translated into practice using QI methods. We increased consistency of practice. Process changes such as improving accessibility of medications and administration information can reliably improve medication compliance. Future Directions Obtain provider feedback to optimize algorithm. Utilize a medication order set to improve ease of compliance to algorithm. Implement standardization of atropine and vecuronium. Address barriers that lengthen duration of event. Acknowledgements Alex Luton, MN, Betty Mugg, RT, Vanessa Philips, BSN, Lindsy Broom, RN, and Mercy Thundiyil, NNP This project was supported by the Evangelina “Evie” Whitlock Fellowship Award in Neonatology. References Marshall TA, Deeder R, Pai S, Berkowitz GP, Austin TL. Physiologic changes associated with endotracheal intubation in preterm infants. Crit Care Med 1984; 12:501-503. Kumar P, et al. Clinical Report-Premedication for Nonemergency Endotracheal Intubation in the Neonate. Pediatrics. 2011. Sarkar S, Schumacher RE, Baumgart S, Donn SM. Are newborns receiving premedication before elective intubation? Journal of Perinatology 2006; 26 (5) 286-9. Carbajal R, Eble B, Anand K. Premedication for tracheal intubation in neonates: confusion or controversy? Semin Perinatol. 2007; 31:309-317. Figure 2. Potential Barriers and Interventions. Texas Pediatric Society Electronic Poster Contest