Patricia Mele DNP (faculty), Loren Murphy MD, Shetal Shah MD, Aruna Parekh MD
Stony Brook Long Island Children’s Hospital, Division of Neonatal Medicine, Department of Pediatrics
Background: Neonatal intubation is critical in resuscitation. Duty-hour restrictions limit real-life training opportunities, increasing reliance on mid-level providers (NNP). The 2012 Neonatal Resuscitation Program (NRP) guidelines emphasize simulation training to improve resuscitation proficiency. Our trainees receive NRP certification with reinforcement during neonatal intensive care unit (NICU) rotation. Assessment of airway skills in this post-training era has not been evaluated.
Objective: To survey intubation practice patterns in a tertiary care Level III NICU.
Methods: From Mar to Oct 2011, a sample of intubations performed by NICU providers was independently evaluated. Data on trainee level, intubation success, reason for failure, location of intubation & proficiency (0-5 Likert Scale) were collected. Demographic data included post-menstrual age & weight at intubation. Data were analyzed using Fisher's Exact Test and ANOVA with Bonferroni correction for multiple comparison.
Results: 282 intubations were analyzed with an overall first-attempt success rate of 52.1%. This rate was higher in the Delivery Room (DR), (62% vs. 47%, p<0.02). Distribution of intubation attempts differed among provider levels (Resident 18%, Fellow 30.8%, NNP 31.9%, Attending 20.2%). NNPs, Attendings & Fellows had increased success rates and higher Likert Scale proficiency scores compared to residents (p<0.0005, p<0.001 & p<0.007 respectively). As expected, proficiency increased with level of experience. There was no difference noted between PGY 2, 3, & 4 (means+ SD 2.98 + 0.77) or the PGY 6, NNP & Attendings (4.5 + 0.85), but there was striking change at level PGY5 when compared to both groups(p<0.001). Failures included airway visualization (28.8%) esophageal intubation (26.6%) & desaturation/bradycardia (14%). Intubation success did not differ based on gestational age.
Conclusions: Resident trainees have decreased intubation success rates compared to other providers despite similar opportunities. The combination of NRP & resident training does not confer competence in infant airway management. While the PGY1 level represents inexperience in intubation skill there is an increase in proficiency at the PGY5 level that reflects exposure at the PGY4 level. We speculate added focus on intubation skill and DR exposure may increase success rates in NICU.
