1. 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 (SpO ≤ 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:
Kumar P, et al. Clinical Report-Premedication for Nonemergency Endotracheal Intubation in the Neonate. Pediatrics
Sarkar S, Schumacher RE, Baumgart S, Donn SM. Are newborns receiving premedication before elective intubation? Journal of Perinatology 2006; 26 (5)
Carbajal R, Eble B, Anand K. Premedication for tracheal intubation in neonates: confusion or controversy? Semin Perinatol. 2007; 31:
Figure 2. Potential Barriers and Interventions.
Texas Pediatric Society Electronic Poster Contest