Clinical paperNeonatal intubation performance: Room for improvement in tertiary neonatal intensive care units☆
Introduction
Tracheal intubation (TI) is a life-saving procedure for acutely ill infants. TI in neonates requires specialized equipment, knowledge and psychomotor skills. Neonatal TIs are low frequency high-stakes events. Sub-optimal performance of neonatal TI has been associated with death and/or significant morbidity.1 Patient, provider, and procedure characteristics all contribute to TI performance. Deficient pediatric provider skills and inadequate training, such as improper laryngoscope handling, have been associated with multiple or prolonged TI attempts, physiologic deterioration, and soft tissue or airway injury.2, 3 Inappropriate tube position (esophageal or right mainstem) has been associated with continued deterioration in patient's cardiorespiratory status, pneumothorax, esophageal perforation and even death if not rapidly identified and corrected.1
TI success rates and provider performance are well described by adult airway researchers.4, 5, 6, 7, 8 This research has guided the development of standards for adult airway management, construction of predictive models of difficult airways, and identification of optimal system factors that are associated with improved success rates, such as advanced airway equipment and teamwork training. In contrast, there is limited data related to pediatric TI. Many previous single institution studies are limited by inadequate sample size and there are wide variations in practice across institutions. The logical first step to improving NICU TI outcomes is to accurately describe the current process of clinical care across multiple institutions. The present study describes current neonatal TI performance on a local and national level at five level III NICU's in the POISE Network (www.members.poisenetwork.com/).
This study aimed to describe TI success rates and provider performance across five level 3 neonatal intensive care units. We hypothesize that neonatal TI clinical performance varies across the spectrum of NICU providers and patients, and that there are modifiable factors associated with success rates. The data collected from this descriptive study will be used to guide the development of future educational interventions to improve patient safety related to TI.
Section snippets
Methods
This prospective, observational study was conducted at five academic level III NICUs that participate in the Pediatric Outcomes in Simulation Education (POISE) research network: Tampa General Hospital, Tampa, FL (University of South Florida Morsani College of Medicine); University of Colorado Hospital, Aurora, CO (University of Colorado School of Medicine); Children's Hospital of Alabama, Birmingham, AL (University of Alabama School of Medicine); The Children's Hospital at Montefiore, Bronx NY
Center characteristics
All 5 centers were level III NICUs in large tertiary care academic teaching institutions with a full spectrum of providers.
Overall success rates
During the study period 203 patients undergoing 456 TI attempts were evaluated with an overall success rate of 44%. Success rates for the first, second and third attempts were 36.5%, 46.5%, and 47.8%, respectively. The majority of patients (82.7%) were successfully intubated by the third attempt (see Fig. 1).
Provider characteristics
Overall, attending physicians and 3rd year neonatal fellows had
Discussion
This prospective, descriptive study describing neonatal TIs performed across five academic level III NICUs. This is one of the first multi-institutional studies describing TI process of care across multiple institutions. In this large cohort more than half of TI attempts resulted in failure, and nearly one in five patients required >3 attempts. The most significant and potentially modifiable factor leading to a failed TI attempt was the level of training of the person performing the procedure.
Conclusion
TI is a high risk, low frequency skill required for the care of critically ill neonates. The likelihood of procedural success varies widely, and is primarily dependent upon the level of training of the provider. This study adds to existing literature demonstrating unsatisfactory pediatric resident TI performance, which has become even more evident with resident duty hour regulations, increasing presence of mid-level providers during neonatal resuscitations, and increased utilization of
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Conflicts of interest
We certify that all of our affiliations with or financial involvement in, within the past 5 years and foreseeable future, any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript are completely disclosed (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, royalties).
Acknowledgements
The authors would like to acknowledge the Yale Pediatric Faculty Scholars Program and the RBaby Foundation for financial support of this project, and Taylor Sawyer, MD and for assistance in reviewing the manuscript.
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2022, Clinics in PerinatologyCitation Excerpt :Endotracheal intubation occurs with high risk of adverse effects, including physiologic disruptions such as hypoxemia, bradycardia via vagal stimulation, and systemic, pulmonary, and intracranial hypertension.24 Although procedural skill is highly variable between providers of different experience levels and at different medical centers, tertiary care centers report success rates of less than half for endotracheal intubation attempts.25 The confluence of frequent physiologic adverse effects and repeated attempts results in increased morbidity, with both intraventricular hemorrhage and severe cognitive impairment, cerebral palsy, hearing impairment, visual impairment, or death at 18 to 22-month follow-up associated with multiple intubation attempts.26,27
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.03.014.