Decreasing Time from Decision to Intubation in Premedicated Neonates: A Quality Improvement Initiative

Abstract

Introduction: Endotracheal intubation carries the risk of discomfort, decompensation, oral trauma, and endotracheal tube malposition. Treatment with premedications reduces complications, increases overall intubation safety, improves pain control, and improves first-pass success. However, time is frequently a barrier to administration. We aimed to decrease the decision-to-intubation time interval from a baseline of 40 minutes to less than 35 minutes over 6 months. Methods: We used the Model for Improvement with multiple plan–do–study–act cycles to reduce the time from decision to successful intubation in nonemergent neonatal intubations. Key drivers were timely administration of medications, availability of skilled personnel and equipment, and efficient use of time. Results: During this project, time from the decision to successful intubation decreased from a historical mean of 40 minutes to a new baseline of 27 minutes. This change represents a 33% decrease, with 80% of intubations occurring within 35 minutes. During this time, success rates remained stable, and medication errors and side effects did not increase. Conclusions: Standard processes to prepare and administer premedications decreased the time from decision to intubation without significant adverse effects, allowing the benefit of premedication administration in a safe and timely manner in nonemergent neonatal intubations.

Premedication practices for neonatal tracheal intubation: Results from the EPIPPAIN 2 prospective cohort study and comparison with EPIPPAIN 1

“…8 As TI is less performed nowadays thanks to noninvasive ventilation, training sessions and standard processes to prepare and administer premedication should be in place in each unit. 8,23 Yet, in our study, even in the centers with a specific protocol, the premedication rates were low and did not exceed 45%. This underlines that implementation of a protocol alone may not lead to sustained quality improvement without routine monitoring and ongoing education to ensure effectiveness.…”

“…To help for the premedication fulfillment and to gain time for the preparation of the drugs, ready‐to‐use kits, as well anticipated prescriptions for the most at risk children could be done in each ICU 8 . As TI is less performed nowadays thanks to noninvasive ventilation, training sessions and standard processes to prepare and administer premedication should be in place in each unit 8,23 . Yet, in our study, even in the centers with a specific protocol, the premedication rates were low and did not exceed 45%.…”

Patient characteristics associated with complications during neonatal intubations

“…This study was approved by the University Hospitals Institutional Review Board. At this institution, data on complications during neonatal intubations have been monitored prospectively since 2017 as part of ongoing quality improvement efforts 8 . A quality data sheet is filled out on intubations occurring in the neonatal intensive care unit (NICU) by the bedside nurse at the time of intubation.…”

“…At this institution, data on complications during neonatal intubations have been monitored prospectively since 2017 as part of ongoing quality improvement efforts. 8 Inclusion criteria were intubations occurring in the NICU between January 2017 and June 2019 with a completed quality data form. Exclusion criteria were delivery room intubations, since quality data is not collected on these intubations, patients with anatomic airway abnormalities, and any intubations without a completed quality data form or with incomplete data regarding complications.…”

Implementation of a Standardized Premedication Bundle to Improve Procedure Success for Nonemergent Neonatal Intubations

“… 3 – 5 , 19 These studies demonstrated that written policies could aid staff in medication administration and reduce AEs without significant threat to clinical deterioration while awaiting medication. 3 , 4 , 8 , 19 , 20 However, despite the extensive body of literature supporting premedication, a 2020 survey of clinicians in 70 countries reported that 12% of practitioners do not use premedication, 32% of units do not have a standardized protocol, and 60% of providers chose premedication according to personal preference. 17 This report suggests that targeted facility-level education and protocol standardization is needed to improve compliance.…”