Increasing Premedication for Neonatal Intubation: A Quality Improvement Initiative

Endotracheal intubation is frequent in the neonatal intensive care unit (NICU) but may result in neonatal distress and instability. Premedication reduces adverse effects, such as hypoxia, bradycardia, and pain. The Specific, Measurable, Achievable, Relevant and Time-Bound aim for this project was to increase premedication use for nonemergent neonatal intubation in a specific NICU from 22% to 80% from March 2021 to May 2023.

We use quality improvement methodology to explain our theory for improvement. Our key driver diagram depicts this initiative's aims, key drivers, and interventions to increase premedication use for neonatal intubation. We defined exclusion criteria and medications, and one author collected demographic data retrospectively after the procedure. The stakeholders summarized the baseline data, performed plan-do-study-act cycles, and showed outcome measures in a statistical process control chart. Statistical analysis used Fisher's exact test to compare categorical variables.

Between 2021 and 2023, 333 infants underwent endotracheal intubation; 130 infants were included. The most common indication for intubation was hypoxemic respiratory failure-52% (68/130). Premedication use increased from 22% to 52%. Among the exclusion criteria, the most common indication for nonpremedication was intubation in the delivery room, 38.4% (78/203). In the premedication group, intubation on the first attempt occurred in 77.6% (52/67) of the cases, versus the nonpremedication group, 66.7% (32/48) (P = 0.3).

Premedication for neonatal intubation increased by 30%, although we did not reach the desired 80% goal. Establishing a premedication bundle, alongside a unit-specific protocol and effective teamwork, marks the initial stride toward enhancing analgesia/sedation practices in the NICU.