194 - Increasing Utilization of Gestational Age Based Table for Initial Intubation in a Level IV Neonatal Intensive Care Unit

Endotracheal tube (ETT) depth in neonates is of critical importance due to significant adverse events when malpositioned. While randomized trials comparing different methods have not shown superiority of any particular method, weight-based method (weight kg +6) has been found to be highly inaccurate in extremely premature infants. Furthermore, the Neonatal Resuscitation Program (NRP) recommends use of gestational age (GA)-based table (Kempley ST, et al, Resuscitation 2008) or nasal-tragal length for initial intubation. Thus, we aimed to reduce right mainstem intubations and ETT placement outside thoracic vertebrae 1-3 (T1-T3) by increasing rate of GA-table.

Objective: Improve utilization of NRP recommended gestation based table for initial intubations, improve ideal ETT position and reduce right mainstem intubations.

Design/Methods:

This was a prospective quality improvement evaluating the method used for determining initial ETT depth, % of ETT repositioning, % of right mainstem intubations, and overall ETT position based on chest radiograph in an academic level IV NICU from February 2021 to September 2022. Retrospective data for baseline comparison was collected from October 2020-January 2021. Interventions included interdisciplinary education to promote utilization of the GA-based table to medical doctors,  nurse practitioners, bedside nurses, and respiratory therapists with three rounds of re-education, creation and dissemination of GA-table “badge buddy” (Figure 1A), education on ideal ETT position imaging and graphical description (Figure 1B), creation of GA-table charts for dedicated airway carts containing intubation supplies, improving documentation of method used for depth determination, and implementation of an annual “No Unplanned Extubations November” initiative to focus all staff on this particular quality improvement project. 




 





Results: A survey of neonatologists revealed the weight (kg)+ 6 method was exclusively used at baseline. After interventions, median use of GA-based table for initial intubation improved to 57%, which was sustained through the end of the project (Figure 2A). Median rates of ETT placement outside T1-T3 improved from 43% at baseline to 29% (Figure 2B). Median rate of right mainstem intubation did not change over time (Figure 2C). Challenges included hesitancy to long standing practice habits, difficulty remembering use of gestation table during emergent intubations and need for continued reminder regarding practice change.

Conclusion(s):

Increasing use of GA-based table for initial intubation improved ideal ETT position and reduced right mainstem intubation.