Transition to Routine Premedication for Nonemergent Intubations in a Level IV Neonatal Intensive Care Unit
26 April 2017
28 August 2017
11 October 2017 (eFirst)
Objective This study aims to test whether implementing a guideline for nonemergent intubation improves the rate of premedication for nonemergent intubations in an academic level IV neonatal intensive care unit (NICU). We further sought to test the hypothesis that neonates who receive premedication for a nonemergent intubation have decreased pain scores at the time of intubation, fewer intubation attempts, and no associated adverse events.
Study Design This was a prospective observational study with ongoing audit and feedback as well as statistical process control analysis. Data collection began on October 1, 2014. Clinical guideline implementation began in October 2015. A percent “P”-chart spanning seven-quarters was constructed with statistical process control analysis plotting premedication rates over time. Student's t-tests or Wilcoxon rank-sum tests were used for secondary outcomes.
Results The mean number of nonemergent intubations given premedications increased from 34 to 82%. The mean pain score was lower when premedications were given: 0.34 (95% confidence interval [CI]: 0.10–0.58) versus 2.8 (95% CI: 1.9–3.6) (p < 0.001). The number of intubation attempts did not differ with premedications.
Conclusion Adopting a guideline with supporting educational initiatives to standardize premedication before nonemergent intubations increased this practice. This regimen lowered clinical pain scores with no difference in the number of intubation attempts.
Rachel Fleishman, MD: Conceptualized and designed the study, monitored, and supervised all data collection from the St. Christopher's Hospital for Children, performed the initial analyses, drafted the initial article, and approved the final article as submitted. Roschanak Mossabeb, MD: Monitored and supervised all data collection from the Temple University Hospital (ultimately not included in the final article) and revised and approved the final article as submitted. Ogechukwu Menkiti, MD: Led the clinical team with guideline implementation and facilitated data collection at the St. Christopher's Hospital for Children, critically reviewed and edited the article, and approved the final article as submitted. Megan Young, PharmD, BCPS: Helped develop the clinical practice guideline, facilitated data collection at the St. Christopher's Hospital for Children, critically reviewed and edited the article, and approved the final article as submitted. Vidhy Bains, Pharm D, BCPS: Helped develop the clinical practice guideline, facilitated data collection at St. Christopher's Hospital for Children, critically reviewed and edited the article, and approved the final article as submitted. David Cooperberg, MD: Provided mentorship and oversight for study design, performed the statistical process control analysis, critically reviewed and edited the article, and approved the final article as submitted.
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