O2113: Improving First-Attempt Success Rate During Neonatal Intubation in a Tertiary NICU

Purpose/Objectives: Multiple intubation attempts in neonates increase the risk of adverse events such as hypoxemia, bradycardia, and airway trauma. This quality improvement (QI) project aims to improve the first-attempt success rate of neonatal intubations by 10% over 12 months in a tertiary neonatal intensive care unit (NICU).

Design/Methods: This project was undertaken using the DMAIC (Define, Measure, Analyze, Improve, Control) framework to systematically address our aim. Key stakeholder meetings were held to identify potential improvement areas, and analysis tools, including a fishbone diagram (Figure 1), the 5 Whys, and an effort-impact grid, guided initial intervention selection. A multidisciplinary project team meets monthly to discuss progress and address any issues. Targeted interventions have been implemented using PDSA (Plan, Do, Study, Act) cycles, including training with a video laryngoscopy (VL) device, implementation of routine video laryngoscopy into the practice, and the dissemination of a mechanism to provide feedback on the device. This project remains in the improvement phase; a current PDSA cycle includes utilizing nasal high-flow therapy during laryngoscopy to promote physiologic stability. We continue to monitor the percentage of first-attempt success with direct laryngoscopy (DL), which is still used in neonates for whom VL is unavailable due to size or patient location, to ensure it is not negatively impacted by increasing use of VL.

Results: Our baseline first-attempt intubation success rate was 41% (30/73). During the improvement phase, that rate has increased to 54% (60/111; p=0.098). Subgroup analysis reveals increased rates of success using both DL (44%) and VL (68%). An annotated control chart (Figure 2) demonstrates the impact of our interventions.

Conclusion/Discussion: This QI project highlights the potential to increase first-attempt success during neonatal intubation. Multiple intubation attempts are associated with adverse events, making first-attempt success rates highly relevant in neonatal care. Our results demonstrate the effectiveness of a structured DMAIC approach, PDSA cycles, and targeted interventions. Furthermore, we did not find evidence that increased utilization of video laryngoscopy negatively impacted proficiency with direct laryngoscopy. We are developing a control plan to ensure the sustainability of these improvements.