Three Interventions To Improve Safety Of Neonatal Intubation

Three Interventions To Improve Safety Of Neonatal Intubation

Infants who must spend time in the neonatal intensive care unit (NICU) are considered “one of the highest-risk groups for adverse events (AEs) in the hospital setting,” according to a 2016 study in Pediatrics.1 While some of these events are due to drug reactions, they report that another common cause is “airway-related events.”

In the medical literature intubation-associated AEs occur in a range from 22 percent to 39 percent of intubations in the NICU. Contributing factors included: how experienced the intubating clinician was, whether muscle relaxants were used, the urgency of intubation and how many intubation attempts were made.

Because of the high variability of NICU intubation procedures, the researchers tested a three-fold plan to improve safety and reduce intubation-associated AEs for neonates. They formed a “multidisciplinary team” comprised of nurses, respiratory therapists and other neonatal physicians, and used such elements as: process flow diagrams, root cause analyses qualitative data and baseline data to develop their three-stage intervention. The intervention targeted “preprocedural preparation, equipment and medication availability, patient-specific situational awareness, team communication, and adequate sedation and neuromuscular blockade for intubation.”

The intervention was aimed at the healthcare providers most likely to perform endotracheal intubations: pediatric residents, neonatal-perinatal medicine fellows, attending neonatologists, neonatal nurse practitioners and hospitalists.

Intervention 1: Intubation Timeout

Prior to the introduction of this intervention, they found that “high quality, pre-procedural timeouts and briefings” were not being regularly performed with intubation. They developed an Intubation Timeout Tool with the goal of standardizing equipment availability and streamlining the flow of communication.

The tool consisted of a checklist that required confirmation of each item checked off and a pre-brief script of questions asked right at the bedside by a performing clinician or supervisor just prior to the procedure. The Timeout Tool remained on a clipboard alongside intubation supplies and crash carts and was “refined through literature review, focus groups…and small trials in the NICU.”

Intervention 2: Premedication for Endotracheal Intubation Algorithm.

Having found that premedications were not routinely used in ET intubation, and that there was quite a lot of variability in these practices, they turned to the Academy of Pediatrics Clinical Report on premedication for nonemergency neonatal intubation.2 From that, they developed an algorithm that advocated the use of certain medications in infants and modified pharmacy processes so that these medications showed up in the medication dispensing systems, “thus improving nursing access to these medications and subsequent workflow.”

Intervention 3: Intubation Computerized Provider Order Entry (CPOE) Set

Lastly, they developed a standardized order set that included pharmacy and nursing elements. The CPOE contained the premedication algorithm and reminders to nurses to use the Intubation Timeout tool, bring neonatal crash carts to the bedside before procedures, and to increase monitoring of vital signs after intubation.

While the implementation of these interventions did increase the time between decision to intubate and actual intubation, it improved the safety of neonatal intubation by reducing AEs, particularly as a result of the Intubation Timeout Tool. It was also “temporally associated with a 10% absolute reduction in AEs that was sustained over the observation period” as well as reductions in bradycardia and hypoxemia during intubation.


1. Dupree Hatch, L. Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit. Pediatrics. 2016. Vol. 138, no.4.
2. Kumar, P. Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics. 2010; 125 (3): 608-615.