Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit.
To improve patient safety in our NICU by decreasing the incidence of intubation-associated adverse events (AEs).



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.



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.



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.
Divisions of Neonatology and leon.d.hatch@vanderbilt.edu.
L Dupree
LD
Hatch
Divisions of Neonatology and.
Peter H
PH
Grubb
Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee.
Amanda S
AS
Lea
Divisions of Neonatology and.
William F
WF
Walsh
Divisions of Neonatology and.
Melinda H
MH
Markham
Critical Care, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
Patrick O
PO
Maynord
Department of Anesthesiology, Children's Hospital of Colorado, Aurora, Colorado.
Gina M
GM
Whitney
Divisions of Neonatology and.
Ann R
AR
Stark
Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, and the Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee; and Veterans Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee.
E Wesley
EW
Ely
D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods*; D008297:Male; D061214:Patient Safety / Q000592:standards*
Crit Care Med. 2013 Mar;41(3):874-85
23328260
J Biomed Inform. 2009 Apr;42(2):377-81
18929686
Pediatrics. 2010 Mar;125(3):608-15
20176672
Best Pract Res Clin Anaesthesiol. 2015 Mar;29(1):27-39
25902464
Neonatology. 2015;108(1):23-9
25967680
Crit Care Med. 1989 Dec;17(12):1293-6
2686934
Am J Perinatol. 2015 Jul;32(9):821-4
25607227
JAMA. 2001 Apr 25;285(16):2114-20
11311101
Am J Med Qual. 2015 Nov-Dec;30(6):543-9
26497490
Arch Dis Child Fetal Neonatal Ed. 2007 Sep;92(5):F391-8
17376782
BMJ Qual Saf. 2015 Sep;24(9):545-9
26089207
Pediatr Crit Care Med. 2014 May;15(4):306-13
24691538
J Pediatr. 2016 Jan;168:62-6.e6
26541424
Arch Dis Child Fetal Neonatal Ed. 2006 Jul;91(4):F279-82
16464937
Pediatrics. 2006 Oct;118(4):1332-40
17015521
Qual Manag Health Care. 2004 Jan-Mar;13(1):17-32
14976904
Pediatrics. 2011 Apr;127(4):783-4
21382950
J Perinatol. 2011 Jan;31(1):38-43
20539274