728 - A strategy to Increase the use of Premedication in Neonatal Intubations

Description of the local problem: The baseline use of Rapid Sequence Intubation (RSI) for intubation in our NICU was 29%, which is suboptimal given the potential benefits of RSI and the 2010 AAP recommendation for RSI use in nonemergent intubations in neonates.

The use of RSI in the neonate has been associated with improved intubation outcomes including increased first attempt success and reduced adverse outcomes.

We reviewed our practice in the unit from June to November 2018 and found low utilization of RSI. We hypothesized that an increased use of RSI would lead to improved first intubation success.

Objective:

To increase RSI compliance at the Christiana Care NICU by 21% from 29% to 50% over 24 months (November 2019 – November 2021) and to describe the process by which we enacted clinical and outlined barriers to change.

Design/Methods:

Context: Christiana Care in Newark, DE is a 70-bed level III NICU.  Medical staff have various levels of training and experience.

We assembled a multidisciplinary team to assess the scope of the problem, identify processes, and design and execute Plan-Do-Study-Act (PDSA) cycles. We conducted a survey among providers to elucidate barriers to implementation (Figure 2) and created a protocol for the implementation of RSI. We created an order set for RSI in the EMR and guided the medical team in placing and renewing orders for infants needing respiratory support.

Outcome Measures include compliance with RSI for intubations occurring in the NICU and Success rate of first intubation attempt. Balancing Measures were Incidence of chest wall rigidity, significant bradycardia (heart rate ≤ 60 bpm), and hypoxia (Saturation ≤ 60%).

Results:

RSI incidence was 20/69 (29%) and compliance in non-emergent use was 20/44 (45%) in 2 months prior to initiation of RSI protocol. At the conclusion of PDSA 1, the use of RSI increased to 44% and in non-emergent intubations to 78%. Non-emergent RSI use remained at 74% over the following 12 months, demonstrating sustainability. Paralytic utilization in RSI was 60%. The first attempt success was similar for intubations with RSI versus without (44/94, 47% vs 100/216, 46%, p= 0.89). Among RSI intubations, the inclusion of a paralytic improved first attempt success (32/56 (57%) vs 12/38 (32%), p =0.02)  (Figure 3). Bradycardia, and hypoxia did not differ between intubations with or without RSI (p=0.051).

Conclusion(s):

We demonstrated increased RSI compliance without an increased incidence of adverse events in babies in a level III NICU using reproducible quality Improvement tools. The use of RSI with paralytic improved first attempts success.