Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit

Hatch LD, Grubb PH, Lea AS, Walsh WF, Markham MH, Maynord PO, Whitney GM, Stark AR, Ely EW. Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit. Pediatrics. 2016 Oct;138(4). pii: e20160069. Epub 2016 Sep 21. PubMed PMID: 27694281; PubMed Central PMCID: PMC5051203.

Objective
To improve patient safety in our NICU by decreasing the incidence of intubation-associated adverse events (AEs).

Methods
We sequentially implemented and tested 3 interventions: standardized checklist for intubation, premedication algorithm, and computerized provider order entry set for intubation. We compared baseline data collected over 10 months (period 1) with data collected over a 10-month intervention and sustainment period (period 2). Outcomes were the percentage of intubations containing any prospectively defined AE and intubations with bradycardia or hypoxemia. We followed process measures for each intervention. We used risk ratios (RRs) and statistical process control methods in a times series design to assess differences between the 2 periods.

Results
AEs occurred in 126/273 (46%) intubations during period 1 and 85/236 (36%) intubations during period 2 (RR = 0.78; 95% confidence interval [CI], 0.63-0.97). Significantly fewer intubations with bradycardia (24.2% vs 9.3%, RR = 0.39; 95% CI, 0.25-0.61) and hypoxemia (44.3% vs 33.1%, RR = 0.75, 95% CI 0.6-0.93) occurred during period 2. Using statistical process control methods, we identified 2 cases of special cause variation with a sustained decrease in AEs and bradycardia after implementation of our checklist. All process measures increased reflecting sustained improvement throughout data collection.

Conclusions
Our interventions resulted in a 10% absolute reduction in AEs that was sustained. Implementation of a standardized checklist for intubation made the greatest impact, with reductions in both AEs and bradycardia.

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