Presenter Status
Fellow
Abstract Type
QI
Primary Mentor
Dianne Lee DO
Start Date
8-5-2023 12:15 PM
End Date
8-5-2023 12:30 PM
Presentation Type
Oral Presentation
Description
Problem Statement/Question: Most providers in our unit are not using the NRP recommended method to determine the initial ETT insertion depth in neonates.
Background/Project Intent (Aim Statement): Endotracheal tube (ETT) depth in neonates is of critical importance due to significant adverse events when malpositioned. While randomized trials comparing different methods have not shown superiority of any particular method, the weight-based method (weight (kg) +6) has been found to be highly inaccurate in extremely low birth weight neonates. Furthermore, the Neonatal Resuscitation Program (NRP) recommends using gestational age (GA)-based table (Kempley ST, et al, Resuscitation 2008) or nasal-tragal length for initial intubation. Thus, we aimed to reduce right mainstem intubations and ETT placement outside thoracic vertebrae 1-3 (T1-T3) by increasing the rate of GA-table use for initial intubations.
Methods (include PDSA cycles): This was a prospective quality improvement project evaluating the method used for determining initial ETT depth, % of ETT repositioning, % of right mainstem intubations, and overall ETT position based on chest radiograph in an academic level IV NICU from February 2021 to September 2022. Retrospective data for baseline comparison was collected from October 2020 through January 2021. Interventions included interdisciplinary education to promote utilization of the GA-based table to medical doctors, neonatal nurse practitioners, bedside nurses, and respiratory therapists with three rounds of re-education, creation and dissemination of GA-table “badge buddy” (Figure 1A), education on ideal ETT position imaging and graphical description (Figure 1B), creation of GA-table charts for dedicated airway carts containing intubation supplies, improving documentation of method used for depth determination, and implementation of an annual “No Unplanned Extubations November” initiative to focus all staff on this particular quality improvement project.
Results: An informal survey of neonatologists revealed that the weight (kg) plus 6 method was exclusively used at baseline. After interventions, median use of the GA-based table for initial intubation improved to 57%, which was sustained through the end of the project (Figure 2A). Median rates of ETT placement outside T1-T3 improved from 43% at baseline to 29% (Figure 2B). Median rate of right mainstem intubation did not change over time (Figure 2C). Challenges included hesitancy to long standing practice habits, difficulty remembering use of gestation table during emergent intubations and need for continued reminder education regarding practice change.
Conclusions: Increasing use of gestation-based table for initial intubation improved ideal ETT position and reduced right mainstem intubation
Included in
Higher Education and Teaching Commons, Medical Education Commons, Pediatrics Commons, Science and Mathematics Education Commons
Increasing Utilization of Gestational Age Based Table for Initial Intubation in a Level IV Neonatal Intensive Care Unit
Problem Statement/Question: Most providers in our unit are not using the NRP recommended method to determine the initial ETT insertion depth in neonates.
Background/Project Intent (Aim Statement): Endotracheal tube (ETT) depth in neonates is of critical importance due to significant adverse events when malpositioned. While randomized trials comparing different methods have not shown superiority of any particular method, the weight-based method (weight (kg) +6) has been found to be highly inaccurate in extremely low birth weight neonates. Furthermore, the Neonatal Resuscitation Program (NRP) recommends using gestational age (GA)-based table (Kempley ST, et al, Resuscitation 2008) or nasal-tragal length for initial intubation. Thus, we aimed to reduce right mainstem intubations and ETT placement outside thoracic vertebrae 1-3 (T1-T3) by increasing the rate of GA-table use for initial intubations.
Methods (include PDSA cycles): This was a prospective quality improvement project evaluating the method used for determining initial ETT depth, % of ETT repositioning, % of right mainstem intubations, and overall ETT position based on chest radiograph in an academic level IV NICU from February 2021 to September 2022. Retrospective data for baseline comparison was collected from October 2020 through January 2021. Interventions included interdisciplinary education to promote utilization of the GA-based table to medical doctors, neonatal nurse practitioners, bedside nurses, and respiratory therapists with three rounds of re-education, creation and dissemination of GA-table “badge buddy” (Figure 1A), education on ideal ETT position imaging and graphical description (Figure 1B), creation of GA-table charts for dedicated airway carts containing intubation supplies, improving documentation of method used for depth determination, and implementation of an annual “No Unplanned Extubations November” initiative to focus all staff on this particular quality improvement project.
Results: An informal survey of neonatologists revealed that the weight (kg) plus 6 method was exclusively used at baseline. After interventions, median use of the GA-based table for initial intubation improved to 57%, which was sustained through the end of the project (Figure 2A). Median rates of ETT placement outside T1-T3 improved from 43% at baseline to 29% (Figure 2B). Median rate of right mainstem intubation did not change over time (Figure 2C). Challenges included hesitancy to long standing practice habits, difficulty remembering use of gestation table during emergent intubations and need for continued reminder education regarding practice change.
Conclusions: Increasing use of gestation-based table for initial intubation improved ideal ETT position and reduced right mainstem intubation
