Novel Multisite Registry Seeks to Improve Neonatal Intubation Safety

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Neonatology Update

Intubation is one of the most common procedures performed in the NICU, and up to 1% of newborns will undergo intubation in the delivery room (DR) after birth. Intubation is lifesaving but also fraught with potential complications, such as adverse events and physiologic (vital sign) deterioration. The National Emergency Airway Registry for Neonates (NEAR4NEOS) was established in 2014 with the objective of improving the safety of neonatal intubation. Children’s Hospital of Philadelphia (CHOP) is the coordinating center for the program.

NEAR4NEOS was adapted from the National Emergency Airway Registry (NEAR) — which captures data on intubation practice and outcomes in the emergency room setting—and the National Emergency Airway Registry for Children (NEAR4KIDS) — which was developed in CHOP’s Pediatric Intensive Care Unit for pediatric patients.

Goals of the National Emergency Airway Registry for Neonates

The NEAR4NEOS Program has 3 overarching goals:

  • to establish a novel multisite neonatal intubation registry
  • to provide infrastructure for single site and multicenter trials of neonatal airway management
  • to implement projects to improve education and the quality of care (QI) for neonatal intubation

The primary aim of the program thus far has been to create the NEAR4NEOS registry, a comprehensive multisite database of neonatal intubation. Participating sites prospectively collect and contribute standardized information about each intubation, including the setting, patient, providers, practice, and outcomes of the procedure. By systematically tracking intubation practice and outcomes, the NEAR4NEOS team can assess how often intubations are successfully performed, identify the frequency and type of adverse events during intubation (including rare events), and evaluate potentially modifiable factors to improve the safety of tracheal intubation. To date, the registry has captured more than 6 000 intubations contributed from 19 centers representing the United States, Canada, Singapore, and Germany.

We recently published the first multicenter report on data collected on 2 607 intubation encounters in 10 centers from October 1, 2014, through March 31, 2017. Findings included:

  • The first intubation was successful in less than half of intubations in both the NICU and DR settings.
  • Pediatric residents rarely participated in NICU intubations and were involved in only 2% of DR intubations.
  • The training level of the first airway provider was significantly associated with first attempt intubation success and success within 2 intubation attempts (P< .001 for both).
  • Adverse events occurred in 18% of NICU intubations and 17% of intubations in the DR.
  • Almost half of NICU intubations and 31% of DR intubations were complicated by severe oxygen desaturations.
  • Video laryngoscopy and paralytic premedication were each independently associated with reduced risk of adverse events during NICU intubations.

The registry also supports the other 2 pillars of NEAR4NEOS: clinical research and quality improvement/education. The first ongoing clinical trial within NEAR4NEOS will identify the impact of video laryngoscopy and standardized coaching on adverse events during intubation across the network. Future research endeavors include ongoing analyses of the registry to identify modifiable factors associated with improved outcomes and to determine methods to assess procedural competency for trainees. Last, we are planning a prospective clinical trial designed to test interventions to prevent oxygen desaturation during intubation in the NICU.

NEAR4NEOS provides opportunities for benchmarking and quality improvement. The program provides each site with a quarterly report of local intubation practice, success, and outcomes. Sites can use this information to identify local targets for improvement. We recently began a QI project in CHOP’s Harriet and Ronald Lassin Newborn/Infant Intensive Care Unit designed to reduce adverse events by using a “bundle” of intubation safety interventions and an intubation safety checklist. This project will serve as a blueprint for multisite implementation of a QI bundle across the network.

Our vision is to improve the safety of intubation for all critically ill newborns. Ongoing work with NEAR4NEOS will enable our team to educate the healthcare community on the risks of neonatal intubation and to identify methods to perform the procedure more safely.

We continue to seek additional partners in academic as well as nonacademic centers. If interested in joining NEAR4NEOS, please email me at