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Am J Perinatol 2024; 41(S 01): e1163-e1171
DOI: 10.1055/s-0042-1760449
Original Article

Assessing Barriers to Utilization of Premedication for Neonatal Intubation Based on the Theoretical Domains Framework

Dianne T. Lee
1   Department of Pediatrics, Children's Mercy Kansas City Hospital, Kansas City, Missouri
,
Christie J. Bruno
2   Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
,
Mona Sharifi
3   Department of Pediatrics, Center for Implementation Science, Yale University School of Medicine, New Haven, Connecticut
,
Veronika Shabanova
2   Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
,
Lindsay C. Johnston
2   Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
› Author Affiliations Funding M.S. was supported by grant number K08HS024332 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
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Abstract

Objective This study aimed to identify barriers and facilitators of premedication utilization for nonemergent neonatal intubations (NIs) in a level IV neonatal intensive care unit (NICU).

Study Design Between November 2018 and January 2019, multidisciplinary providers at a level IV NICU were invited to participate in an anonymous, electronic survey based on Theoretical Domains Framework to identify influences on utilization of evidence-based recommendations for NI premedication.

Results Of 186 surveys distributed, 84 (45%) providers responded. Most agreed with premedication use in the following domains: professional role/identity (86%), emotions (79%), skills (72%), optimism (71%), and memory, attention, and decision process (71%). Domains with less agreement include social influences (42%), knowledge (57%), intention (60%), belief about capabilities (63%), and behavior regulation (64%). Additional barriers include environmental context and resources, and beliefs about consequences.

Conclusion Several factors influence premedication use for nonemergent NI and may serve as facilitators and/or barriers. Efforts to address barriers should incorporate a multidisciplinary approach to improve patient outcomes and decrease procedure-related pain.

Key Points

  • Premedication for NIs can optimize conditions and decrease rates of tracheal intubation adverse events but there is significant international and institutional variation for premedication use for NI.

  • Guided by implementation science methods, the Theoretical Domains Framework was utilized to construct a novel assessment tool to determine potential barriers to and facilitators of the use of premedication for NI.

  • Several factors influence premedication for nonemergent NI.

Keywords

neonatal intubation - premedication - Theoretical Domains Framework - implementation science

Authors' Contributions

D.T.L., M.S., C.J.B. and L.C.J. conceptualized and designed the study, analyzed the data, drafted the initial manuscript, and reviewed and revised the manuscript. D.T.L. coordinated and supervised data collection. V.S. performed statistical analyses. All authors interpreted the data, and critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.


Ethical Approval and Patient Consent

Institutional Review Board Human Subjects Committee deemed the study to be exempt from review (Yale HSC no.: 2000023147). The study was performed in accordance with the Declaration of Helsinki.




Publication History

Received: 17 June 2022

Accepted: 08 December 2022

Article published online:
16 January 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Foglia EE, Ades A, Sawyer T. et al; NEAR4NEOS Investigators. Neonatal intubation practice and outcomes: an international registry study. Pediatrics 2019; 143 (01) e20180902
    CrossrefPubMedGoogle Scholar
  • 2 Sarkar S, Schumacher RE, Baumgart S, Donn SM. Are newborns receiving premedication before elective intubation?. J Perinatol 2006; 26 (05) 286-289
    CrossrefPubMedGoogle Scholar
  • 3 Durrmeyer X, Daoud P, Decobert F. et al. Premedication for neonatal endotracheal intubation: results from the epidemiology of procedural pain in neonates study. Pediatr Crit Care Med 2013; 14 (04) e169-e175
    CrossrefPubMedGoogle Scholar
  • 4 Ozawa Y, Ades A, Foglia EE. et al; National Emergency Airway Registry for Neonates (NEAR4NEOS) Investigators. Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events. J Perinatol 2019; 39 (06) 848-856
    CrossrefPubMedGoogle Scholar
  • 5 Krick J, Gray M, Umoren R, Lee G, Sawyer T. Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study. J Perinatol 2018; 38 (06) 681-686
    CrossrefPubMedGoogle Scholar
  • 6 Eccles M, Mittman B. Welcome to implementation science. Implement Sci 2006; 1 (01) DOI: 10.1186/1748-5908-1-1.
    CrossrefPubMedGoogle Scholar
  • 7 Atkins L, Francis J, Islam R. et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci 2017; 12 (01) 77
    CrossrefPubMedGoogle Scholar
  • 8 Smith JD, Corace KM, MacDonald TK. et al. Application of the Theoretical Domains Framework to identify factors that influence hand hygiene compliance in long-term care. J Hosp Infect 2019; 101 (04) 393-398
    CrossrefPubMedGoogle Scholar
  • 9 Huijg JM, Gebhardt WA, Crone MR, Dusseldorp E, Presseau J. Discriminant content validity of a Theoretical Domains Framework questionnaire for use in implementation research. Implement Sci 2014; 9 (01) 11
    CrossrefPubMedGoogle Scholar
  • 10 Taylor N, Lawton R, Moore S. et al. Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline. BMC Health Serv Res 2014; 14: 648
    CrossrefPubMedGoogle Scholar
  • 11 Dhallu MS, Baiomi A, Biyyam M, Chilimuri S. Perioperative management of neurological conditions. Health Serv Insights 2017; 10: 1178632917711942
    PubMedGoogle Scholar
  • 12 Kumar P, Denson SE, Mancuso TJ. Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics 2010; 125 (03) 608-615
    CrossrefPubMedGoogle Scholar
  • 13 Davis PJ, Cladis FP, Motoyama EK. Smith's Anesthesiology for Infants and Children. 10th ed.. Philadelphia: PA: Elsevier; 2011
    Google Scholar
  • 14 Whalen AM, Merves MH, Kharayat P. et al. Validity evidence for a novel, comprehensive bag-mask ventilation assessment tool. J Pediatr 2022; 245: 165-171.e13
    CrossrefPubMedGoogle Scholar
  • 15 Johnston L, Sawyer T, Nishisaki A. et al; INSPIRE Research Network. Neonatal intubation competency assessment tool: development and validation. Acad Pediatr 2019; 19 (02) 157-164
    CrossrefPubMedGoogle Scholar
  • 16 Johnston LC, Chen R, Whitfill TM, Bruno CJ, Levit OL, Auerbach MA. Do you see what I see? A randomised pilot study to evaluate the effectiveness and efficiency of simulation-based training with videolaryngoscopy for neonatal intubation. BMJ Simul Technol Enhanc Learn 2015; 1 (01) 12-18
    CrossrefPubMedGoogle Scholar
  • 17 Toews AJ, Martin DE, Chernomas WM. Clinical debriefing: a concept analysis. J Clin Nurs 2021; 30 (11-12): 1491-1501
    CrossrefPubMedGoogle Scholar
  • 18 Nishisaki A, Donoghue AJ, Colborn S. et al. Effect of just-in-time simulation training on tracheal intubation procedure safety in the pediatric intensive care unit. Anesthesiology 2010; 113 (01) 214-223
    CrossrefPubMedGoogle Scholar
  • 19 Nishisaki A, Lee A, Li S. et al; for National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Sustained improvement in tracheal intubation safety across a 15-center quality-improvement collaborative: an interventional study from the National Emergency Airway Registry for Children Investigators. Crit Care Med 2021; 49 (02) 250-260
    CrossrefPubMedGoogle Scholar
  • 20 Milési C, Baleine J, Mura T. et al. Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial. Arch Dis Child Fetal Neonatal Ed 2018; 103 (03) F221-F226
    CrossrefPubMedGoogle Scholar
  • 21 Baleine J, Milési C, Mesnage R. et al. Intubation in the delivery room: experience with nasal midazolam. Early Hum Dev 2014; 90 (01) 39-43
    CrossrefPubMedGoogle Scholar
  • 22 Smith KA, High K, Collins SP, Self WH. A preprocedural checklist improves the safety of emergency department intubation of trauma patients. Acad Emerg Med 2015; 22 (08) 989-992
    CrossrefPubMedGoogle Scholar
  • 23 Allen KA. Premedication for neonatal intubation: which medications are recommended and why. Adv Neonatal Care 2012; 12 (02) 107-111
    CrossrefPubMedGoogle Scholar
  • 24 Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm 2011; 68 (14) 1320-1330
    CrossrefPubMedGoogle Scholar
  • 25 Oc B, Bashshur M. Followership, leadership and social influence. Leadersh Q 2013; 24 (06) 919-934
    CrossrefPubMedGoogle Scholar
  • 26 Shea CM. A conceptual model to guide research on the activities and effects of innovation champions. Implement Res Pract 2021; 2: 263348952199044
    CrossrefPubMedGoogle Scholar
  • 27 Deering S, Johnston LC, Colacchio K. Multidisciplinary teamwork and communication training. Semin Perinatol 2011; 35 (02) 89-96
    CrossrefPubMedGoogle Scholar
  • 28 Bohlin K, Gudmundsdottir T, Katz-Salamon M, Jonsson B, Blennow M. Implementation of surfactant treatment during continuous positive airway pressure. J Perinatol 2007; 27 (07) 422-427
    CrossrefPubMedGoogle Scholar
  • 29 McPherson C. Sedation and analgesia in mechanically ventilated preterm neonates: continue standard of care or experiment?. J Pediatr Pharmacol Ther 2012; 17 (04) 351-364
    PubMedGoogle Scholar