A tiny baby intubation team improves endotracheal intubation success rate but decreases residents’ training opportunities

To assess the educational and clinical impact of a tiny baby intubation team (TBIT). Retrospective study comparing endotracheal intubation (ETI) performed: pre-implementation of a TBIT (T1), 6 months post-implementation (T2), and 4 years post-implementation (T3). Post-implementation (T2), first-attempt success rate in tiny babies increased (44% T1; 59% T2, p = 0.04; 56% T3, p = NS) and the proportion of ETIs performed by residents decreased (53% T1; 37% T2, p = 0.001; 45% T3, p = NS). After an educational quality improvement intervention (prioritizing non-tiny baby ETIs to residents, systematic simulation training and ETI using videolaryngoscopy), in T3 residents’ overall (67% T1; 60% T2, p = NS; 79% T3, p = 0.02) and non-tiny baby ETI success rate improved (72% T1; 60% T2, p = NS; 82% T3, p = 0.02). A TBIT improves success rate of ETIs in ELBW infants but decreases educational exposure of residents. Educational strategies may help maintain resident procedural competency without impacting on quality of care.


INTRODUCTION
Endotracheal intubation (ETI) is a common procedure performed in the neonatal intensive care unit (NICU). Although it is often lifesaving in preterm infants, ETI has several associated complications, including but not limited to airway injury, hypoxemia, bradycardia, systemic and intracranial hypertension with a potential for intraventricular hemorrhage [1][2][3][4][5]. Extremely low birth weight (ELBW) infants are at increased risk of neurological injury related to ETI, and multiple attempts are associated with worse outcomes [6,7]. Increased physician training level is associated with increased success rate of ETI [8], which emphasizes the value of ETI being done by the most qualified person.
With the objective to provide the best quality of care, some NICUs have implemented specialized tiny baby teams dedicated to the care of ELBW patients [9][10][11]. With the increased use of noninvasive ventilation, fewer medical indications for ETI in neonates (e.g., meconium suctioning in the delivery room and less invasive surfactant administration), the presence of other healthcare professionals in the NICU (neonatal nurse practitioners, dedicated respiratory therapists), an increased number of trainees in pediatrics and neonatology, and implementation of reduced working hours directives, trainees' opportunities to intubate have decreased [12]. We hypothesized that the implementation of a tiny baby intubation team (TBIT) would further limit medical trainees' exposure to the procedure. Although for immediate delivery of care the creation of a TBIT might improve quality of care, we questioned the long-term impact of decreased exposure for trainees, and the future global quality of care of newborns once these trainees are practicing physicians. Thus, the aim of this study is to assess the impact of implementing a TBIT on the quality of care surrounding ETI as well as its educational impact.

MATERIALS/SUBJECTS AND METHODS Study design and setting
We conducted a retrospective study at Sainte-Justine University Hospital (Quebec, Canada), a Mother and Child university hospital. The high-risk pregnancy Obstetrics and Gynecology Department has approximately 3500 births yearly. The NICU is a 65-bed level 3-4 unit and admits 1000 babies annually of which on average 75 are less than 1000 g. Historically, approximately 600 neonatal ETIs were carried out in the NICU and delivery room each year. In the past few decades, the number of neonatal ETIs has decreased. In 2009, 500 ETIs were carried out, compared to 220 in 2015, and approximately 160 in 2021. During the 3-year core training, pediatric residents complete four 1-month rotations and cover night calls in the NICU. This exposure to neonatal care did not change throughout the three time periods of the study. This study was approved by the institutional review board.

Study population
All ETIs performed in the delivery room or NICU during three different time periods were evaluated: October 2012 to January 2014 (before implementation of a TBIT; T1), July 2014 to December 2015 (6 months after implementation of a TBIT; T2), and October 2018 to January 2020 (4 years after implementation of a TBIT; T3). Dates of T2 were chosen as to allow transition time in change of practice. Data of T2 were presented to the team during the summer of 2016 and clinical and educational quality improvement strategies were implemented during the fall of 2016. These strategies included the following action plans: (1) ETIs of a non-ELBW patient were in priority assigned to residents; (2) trainees completed a procedural logbook throughout their residency program and when an ETI occurred, the resident present in the NICU that day with the least exposure was prioritized; (3) all novice intubators, for a minimum of their first five intubation courses, had to use the videolaryngoscope (VL) to perform an ETI as to facilitate guidance by the supervisor throughout the procedure [13,14]; and (4) residents received systematic ETI simulation training before performing a clinical ETI on three different occasions: the beginning of the academic year, beginning of the neonatology rotation and during weekly mock codes [14]. We decided to plan follow-up 2 years later (T3) to allow implementation and effect of action plans. There were no exclusion criteria. ETI premedication protocol remained the same throughout study periods and included atropine (20 mcg/kg), fentanyl (4 mcg/kg) and succinylcholine (2 mg/kg).

Definitions
For the purpose of this study, we defined tiny babies as infants with corrected gestational age of less than 29 weeks or with a weight less than 1000 g at time of ETI. Patients that fit the abovementioned criteria and that underwent intubation during their hospitalization in the delivery room or NICU were included.
The TBIT included healthcare professionals (pediatric residents, neonatal-perinatal medicine fellows, neonatologists, neonatal nurse practitioners, respiratory therapists) who performed successful ETI on first or second attempt in at least four of their last five ETIs. A staff neonatologist was responsible to keep an up-todate record of the TBIT member list. In the time period prior to TBIT implementation, assignment of ETI was left to the discretion of the staff neonatologist on service and was largely influenced by the clinical status of the infant. Resident ETI success was defined as an ETI when the resident was the first person to attempt intubation and was successful on their first or second attempt.

Data collection
For each ETI performed, patients' clinical information including birth weight, gestational age at birth, corrected gestational age at intubation, weight at ETI, indication for intubation, and procedural complications were collected. Information on the healthcare provider performing ETI, and number of attempts were also gathered. An attempt at ETI was defined as insertion of the laryngoscope blade into the airway. Data was collected in a database where a standardized sheet was used for each ETI. Data were then extracted for statistical analysis.
Primary outcomes included first-attempt success rates (among all neonates and in babies fitting the tiny baby definition) and proportion of ETIs attempted by pediatric residents. Secondary outcomes included second-attempt success rates (among all neonates and in babies fitting the tiny baby definition), number of attempts per ETI and residents' success rate during ETI. Reasons for failed intubation in T3 were also collected in order to help identify future quality improvement strategies.

Data analysis
Statistical analysis was carried out with SPSS version 25 (SPSS, Chicago, IL, USA). Categorical variables were compared between the three time periods by a single 2 × 3 χ 2 , and, if p < 0.05, individual comparisons of period 1 vs 2 and 2 vs 3 were then performed. First-attempt success rate was analyzed by logistic regression, and number of attempts per ETI was analyzed by ordinal regression. Continuous variables were analyzed using independent t-test or analysis of variance, with post hoc intergroup tests by Least Significant Difference. We considered p < 0.05 as statistically significant.

RESULTS
A total of 646 ETIs were conducted during three different time periods: T1 (before implementation of a TBIT; n = 249), T2 (6 months after implementation of a TBIT; n = 196), and T3 (4 years after implementation of a TBIT; n = 201). Forty-one percent of ETIs were performed on tiny babies. Table 1 shows the patient demographics for each period.
Primary and secondary outcomes are presented in Table 2. Firstattempt success rate in tiny baby patients increased between T1 and T2 from 44 to 59% (p = 0.04) and was stable thereafter, at 56% in T3 (p = NS). On logistic regression analysis the time period remained a significant factor in first-attempt success rate among tiny baby patients after correcting for body weight at the time of intubation, and intubation in the NICU rather than the delivery room. First-attempt success rate in non-tiny baby patients increased from 49% in T2 to 64% in T3 (p = 0.02). The number of attempts per ETI for tiny baby patients decreased right after the implementation of a TBIT, from a median of 2 attempts in T1 (IQR 1, 2) to 1 attempt in T2 (IQR 1, 2, p = 0.02). The number of attempts per ETI for non-tiny baby patients decreased several years after the implementation of a TBIT, from a median of 2 attempts in T2 (IQR 1, 2) to 1 attempt in T3 (IQR 1, 2, p = 0.02). These results remained significant after correcting for body weight at the time of ETI and location of intubation, by ordinal regression analysis.
The proportion of ETIs performed by residents decreased after the implementation of a TBIT, going from 53% in T1 to 37% in T2 (p = 0.001), regardless of patients' weight and gestational age at ETI. This proportion increased, although not statistically significantly, from T2 to T3 for all ETIs possibly due to an increase in ETIs in non-tiny babies. The decrease in proportion of ETI performed by residents in tiny babies during T2 remained stable during T3 (26% vs 19%, p = NS) supporting the adhesion to the TBIT concept in T3. The proportion of ETI performed using the VL increased from 14% during T2 to 28% in T3 (p < 0.001). This increase in T3 is mainly in non-tiny babies where 36% of ETI were performed using the VL compared to only 13% of ETI in tiny babies. After the implementation of action plans, residents' overall and non-tiny baby ETI success rate improved going from 60% in T2 to 79% in T3 (p = 0.02) for overall ETIs and from 60% in T2 to 82% in T3 for ETIs performed in non-tiny babies (p = 0.02). Residents' success rate remained stable for tiny baby ETIs between T2 (60%) and T3 (62%) (p = NS).
Reasons for failed ETI are presented in Table 3. Difficulty with endotracheal insertion, difficulty with glottic visualization, and desaturation were the most common reasons for failed intubation in tiny and non-tiny babies.

DISCUSSION
This study is the first to assess the impact of the implementation of a TBIT on patient care in the NICU and its repercussions on trainees' clinical exposure. It highlights the balance that needs to be made between quality of care and education. Following implementation of a TBIT, first-attempt success rate increased and the number of attempts per ETI decreased in tiny babies, but the proportion of ETIs performed by residents decreased. After an educational quality improvement intervention, the proportion of ETIs performed by residents increased in favor of non-tiny babies and their ETI success rate improved overall and in non-tiny babies. Difficulty with endotracheal insertion, difficulty with glottic visualization, and desaturation were the most common reasons for failed intubation in tiny and non-tiny babies.   Our first goal was to assess the impact of implementing a TBIT on the quality of care surrounding ETI. After implementation of a TBIT, first-attempt success rate for tiny baby patients increased in T2 and was maintained thereafter in T3. In addition, the number of attempts per intubation in tiny baby patients decreased in T2 and was maintained during T3, also illustrating continued implementation of the TBIT protocol and strategies throughout the study. Study results show improved patient care after implementation of a TBIT. In fact, the number of attempts per intubation is predictive of the clinical outcome in patients requiring resuscitation maneuvers [4,6,7]. Morris et al. also showed similar results where the use of specialized small baby units improved clinical outcomes in extremely low birth weight (EBLW) infants [10]. Our premedication protocol is universally used in the NICU except very rare cases of inability to insert venous access, and was unchanged throughout the three time periods, to ensure optimal procedural conditions.
Our second goal was to assess the educational impact of implementing a TBIT. Our results show that the proportion of total ETIs performed by residents significantly decreased after the implementation of a TBIT. This highlights the dilemma that emerges once a TBIT is implemented in the NICU and its direct impact on trainees' clinical exposure. Current literature shows that residents are the first to perform ETI in only 15-38% of ETIs performed in the NICU [15][16][17]. Combined with a decreased number of clinically indicated newborn ETIs and an increasing number of allied health professionals that also require intubation training (e.g., transport teams), the number of resident-performed ETIs has significantly decreased in the past decades [18]. Adding the constraint of a TBIT decreased even further the number of ETIs available to residents. When residents become independent practicing physicians, they may become the main provider of neonatal ETI in their future employment. ETI is therefore an important educational objective and clinical imperative for their training. Ensuring their competence is important for future quality of the care they will provide.
After the implementation of a TBIT and analyses of its impact, action plans were implemented with the following objectives, to: (1) increase exposure of residents to ETI of non-tiny baby patients; (2) implement universal simulation training of ETI with residents; and (3) increase the use of VL to train residents during clinical ETI. As a result of these recommendations, during T3, there was an increase in the proportion of total ETI performed by residents, mainly by increasing ETI of non-tiny baby patients. First-attempt success rate in non-tiny baby patients increased in T3. When compared to the TBIT performance rates, results show that residents can reach similar numbers. Interestingly, following the institution of our action plans, the number of attempts per ETI for non-tiny baby patients also decreased in T3. These first-attempt ETI success rates for residents are greater than the majority reported in the current literature, which are usually between 30 and 70% [9]. Our results show that, to maintain sufficient clinical exposure after the implementation of a TBIT, redistribution of non-tiny baby patients' ETIs to residents is important. Once junior residents are clearly defined as having priority for non-tiny baby ETIs, a teaching approach tailored to the residents' level of skills can be achieved.
Other factors such as the use of experiential educational methods (e.g., simulation) and the increasing use of VL, might also contribute to the improved success rate throughout the different time periods [19,20]. Simulation has been used to improve residents' performance and compensate for the decreasing exposure to ETI. High fidelity simulation has become a cornerstone of procedural training during residency but the impact on patient outcome has yet to be clearly defined [21][22][23]. VL can also be used as an educational tool as it facilitates guidance throughout the procedure and allows us to develop the set of skills required when using a direct laryngoscope [13,14]. In our NICU, the use of VL increased approximately by 14% between 2015 and 2019 and mainly in favor of non-tiny babies. Three clinical trials have shown the educational impact of VL during ETI by the increase in success rate of trainees performing ETI with the VL [13,24,25]. Further studies are required to assess the impact of VL use on clinical outcomes in the NICU specifically [26].
Our final finding was that during T3 the main reasons for failed ETI attempt were: difficulty with endotracheal tube insertion, difficulty with glottic visualization, and desaturation both in tiny and non-tiny babies. As the VL offers improved glottic visualization [27], increasing its use, especially in tiny babies, might improve ETI success rate. The VL used in our NICU is the C-MAC VL (Karl Storz©, Tuttlingen, Germany) which currently offers Miller blades 0 and 1. These blade sizes limit its use in the smallest babies. Recently, the Neoview (International Biomedical©, Austin, Texas, USA), which offers Miller blades 000, 00, 0 and 1, has become available and its use in tiny babies might aid in improving ETI success rate for this patient population. Novel ideas, such as the use of nasal high-flow therapy during neonatal ETI, are emerging and improve the likelihood of successful ETI attempt [28]. VL, high fidelity simulation, and high-flow therapy are valuable tools that should be utilized to enhance resident training and quality of care.
There are a number of limitations to our study. To allow for better interpretation of research results, groups could have been more precisely defined. For example, the cumulative number of years of training might have been a useful measure to objectively characterize each team: TBIT and residents in training. Data stratification for the level of acuteness or severity of the patient's clinical state for each ETI could have been a useful adjunct. The environment in which ETIs were performed might have had an impact on ETI success rate. Accounting for this might have offered more accurate comparisons between teams.

CONCLUSION
This study is the first to report the impact of a TBIT on ETI success rate and residents' training opportunities. As development of a TBIT decreases the number of ETIs performed by residents in training, conscious efforts must be made in finding alternative methods to ensure appropriate exposure to the procedure. Prioritizing resident ETI experience in non-tiny babies, videolaryngoscopy use and simulation-based training, are important elements that need to be emphasized to ensure adequate procedural training.

DATA AVAILABILITY
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Table 3. Reasons for failed endotracheal intubation attempts in T3 (more than one reason can apply to each intubation attempt).