662 - The use of a video laryngoscope to improve first attempt success rates in less experienced providers

Literature suggests rates of successful neonatal intubation on the first attempt are approximately 50%. In the premature neonate, hemodynamic and saturation changes experienced during intubation attempts may contribute to severe intraventricular hemorrhage, death, or neurodevelopmental impairment. The use of video laryngoscopes (VL) has shown improved first attempt success rates for intubations of infants in the emergency room, operating room, and neonatal intensive care unit (NICU). The NICU at Rainbow Babies and Children’s Hospital has an overall intubation first attempt success rate of 57% (excluding delivery room intubations), with median fellows’ first attempt success at 80%, and median Advanced Practice Providers’ (APP) first attempt success at 23%.

Objective:

Through the use of a VL, we will improve our unit’s overall intubation first attempt success rate to 80% by June 2024. We have an interim SMART Aim to improve first attempt success rate of APPs to 50% by June 2023, and 70% by December 2023. Our Key Driver Diagram addresses the introduction of a new piece of equipment to our unit and associated primary and secondary drivers.

Design/Methods:

Using the Model for Improvement and through many plan-do-study-act cycles, we introduced the VL to our unit in November 2021. We began by limiting use of the VL to members of the Quality Improvement team, then broadened to neonatology fellows by January 2022. We focused on coaching strategies to ensure fellows were comfortable with the device as well as recognizing and correcting common missteps of intubation. APPs first began using the VL in August 2022, after demonstrating competence on a mannequin. Process measures are the number of times the VL is used. Balancing measures are intubation complications including desaturations and bradycardias.

Results:

Since the introduction of the VL, although special signals in improving overall first attempt success rates have not yet been realized and the fellow first attempt success rate with the VL is 70%, the first attempt success rate for our APPs using the VL is 43%, an improvement from their baseline. Data is limited, as only 35% of intubations in the NICU are performed using the VL. There has been no overall difference in desaturation or bradycardia events during intubations with the VL versus direct laryngoscopy.

Conclusion(s):

Introducing VL to our unit has been difficult due to buy in, but early results suggest the use of VL improves first time success rate in APPs with less experience. We aim to continue to use this tool to improve first attempt success for less experienced providers and our unit overall.