NCQAC Advisory Opinion 3.0: Neonatal Intubation
Page 1 of 4
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Department of Health
Nursing Care Quality Assurance Commission
Advisory Opinion
The Nursing Care Quality Assurance Commission (NCQAC) issues this advisory opinion in accordance with WAC 246-840-800. An advisory opinion
adopted by the Nursing Commission is an official opinion about safe nursing practice. The opinion is not legally binding and does not have the force and
effect of a duly promulgated regulation or a declaratory ruling by the Nursing Commission. Institutional policies may restrict practice further in their setting
and/or require additional expectations to assure the safety of their patient and//or decrease risk.
Title:
Neonatal Intubation and Related Procedures
Number:
NCAO 3.0
References:
RCW 18.79 Nursing Care: http://apps.leg.wa.gov/RCW/default.aspx?cite=18.79
WAC 246-840 Practical & Registered Nursing:
http://apps.leg.wa.gov/WAC/default.aspx?cite=246-840
Nursing Scope of Practice Decision Tree:
http://www.doh.wa.gov/Portals/1/Documents/Pubs/609305.pdf
Contact:
Deborah Carlson, MSN, RN
Phone:
360-236-4725
Email:
Effective Date:
3-14-14
Supersedes:
Not Applicable
Approved By:
Nursing Care Quality Assurance Commission
Conclusion Statement
The Nursing Care Quality Assurance Commission concludes that registered nurses (RNs) may perform neonatal
intubation in emergency or elective situations up to their lawful and individual scope of practice based on
education, skills, knowledge and abilities. During neonatal intubation, other resuscitative activities may be
performed simultaneously. Therefore, the RN should be competent in performing related activities under the
direction of an authorized provider as identified through institutional policy, procedures, and standing orders.
These may include thoracentesis, medication administration (including rapid sequencing intubation), umbilical
venous or arterial catheterization, intraosseus needle placement, laryngeal mask placement, other advanced life
support activities, post-resuscitation management and transport. This document provides guidance and
recommendations relevant to neonatal intubation and other neonatal emergency procedures. The commission
advises nurses to use the Scope of Practice Decision Tree to determine if neonatal intubation or related activities
are within the nurse’s individual scope of practice. Completion of formal certifications in advanced resuscitation
does not imply that a RN has the competence to perform neonatal resuscitation or related activities. Due to the
complexity of the activities and nursing judgment required, the commission determines it is beyond the scope of a
licensed practical nurse (LPN) to lead these activities. LPNs may be a member of the team and assist in
performing individual activities during neonatal resuscitation up to their lawful and individual scope of practice
based on the Decision Tree.
NCQAC Advisory Opinion 3.0: Neonatal Intubation
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Background and Analysis
The commission received a formal request to issue an advisory as to whether RNs in the neonatal intensive care
unit may intubate and perform other lifesaving measures in the absence of a physician or neonatal nurse
practitioner. Some states allow RNs to intubate if they have special training; some allow it only in emergency
situations; others allow only advanced practice nurses to intubate neonates. The Air and Surface Transport Nurses
Association (ASTNA) notes that neonatal intubation is an expectation of practice in that specialty.
Neonatal resuscitation skills are essential for all health care providers who are involved in the delivery of
newborns. In the United States, the transition from fetus to newborn requires intervention by a skilled individual
or team in approximately ten percent of all deliveries (Bissiner, 2012) with 81 percent born in non-teaching,
nonaffiliated Level I or II hospitals. According to ASTNA (2007), about one percent of newborns require
extensive resuscitation. When newborn infants become ill and need specialized care, members of the health care
team must know what to do in a timely and effective manner. Specialized training is available for nurses and other
team members such as the S.T.A.B.L.E. Program: Post-Resuscitation/Pre-Transport Stabilization Care of Sick
Infants. This program focuses on stabilization after delivery room resuscitation and preparation for transport.
RNs in neonatal intensive care units and labor and delivery settings play a significant role in advanced airway
management. A non-physician neonatal resuscitation team is one way of providing quality advanced resuscitation
where a physician or advanced practice nurse is not in-house. Nurses involved in neonatal intubation may also be
members of a transport team. The American Academy of Pediatrics’ (AAP) Neonatal Resuscitation Program™
(NRP) is an educational program jointly sponsored with the American Heart Association. The program is
designed to teach resuscitation to nurses, physicians, and respiratory therapists based on simulation, leadership,
communication and teamwork. Research shows that with appropriate education and continued clinical
competency, neonatal nurses in emergency and transport settings can safely resuscitate newborns using advanced
airway management techniques, including intubation (Neal D., Steward D. and Grant C.C., 2008; Raghuveer, T.S.
and Cox, A.J., 2011).
Maintaining high levels of readiness for neonatal resuscitation in small- or low-risk community hospitals may be
challenging. Nurses may not receive enough exposure to these events in training or in practice to become
proficient or maintain proficiency. Telehealth is being used by some institutions to address this problem by adding
the participation of remote expert neonatal care providers during events and for ongoing educational and training
opportunities.
Laws and Rules
Washington State nursing laws and rules do not explicitly prohibit the performance of neonatal intubation and
related activities by nurses. RNs and LPNs are accountable and responsible for their individual practices (RCW
18.79, WAC 246-840). RNs may perform acts requiring substantial specialized knowledge, judgment, and skill;
they execute medical regimens prescribed by authorized providers: advanced registered nurse practitioner,
physician and surgeon, osteopathic physician and surgeon, physician assistant physician, osteopathic physician
assistant, or a licensed midwife acting within his or her scope of practice (RCW 18.79.040). These activities
include medication administration, treatments, tests, and injections; whether or not piercing of tissues is involved
and whether or not a degree of independent judgment and skill is required. RNs may also perform minor surgery
(RCW 18.79.240).
LPNs may execute medical regimens under the direction of an authorized provider or under the direction and
supervision of an RN. LPNs may perform acts requiring knowledge, skill, and judgment in routine situations
(WAC 246-840-705). In complex care situations, a LPN functions as an assistant to the RN or other authorized
provider (WAC 246-840-705).
NCQAC Advisory Opinion 3.0: Neonatal Intubation
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Washington State nursing laws and rules do not define standing orders. Therefore, the commission refers to the
federal Centers for Medicare and Medicaid Services (CMS) definitions of standing orders, order sets, pre-printed
orders and protocols for patient orders. The CMS definition of standing orders includes pre-printed order sets and
protocols as standing orders, whether they are in printed or electronic form. (CMS, 2012). CMS requires orders be
based upon nationally recognized evidence-based guidelines and recommendations. Medical, pharmacy and
nursing leadership must develop, review, and approve standing orders. Institutions are not required to use
standing orders. Insurance companies may not reimburse for services provided using standing orders. Other
factors such as accreditation standards and liability or risk management concerns may influence whether an
institution uses standing orders or allow RNs to perform neonatal resuscitation and related activities.
Recommendations
Standards of Care
Nurses should follow current practice standards relevant to neonatal intubation, neonatal resuscitation, and
neonatal transport. Published guidelines include the AAP NRP™, the National Association of Neonatal Nurses
(NANN) Neonatal Nursing Transport Standards: Guideline for Practice; the Air and ASTNA Patient Transport:
Principles and Practices; and the AAP Guidelines for Air and Ground Transport of Neonatal and Pediatric
Patients.
Competency and Certification
The commission recommends RNs successfully complete NRP™ and/or the ASTNA Certified Transport
Registered Nurse/Certified Flight Registered Nurse program(s), depending on relevance to the roles and
responsibilities. The NANN Neonatal Nursing Transport Standards: Guideline for Practice competency
standards may also be used. Completion of one or more programs does not imply that a nurse is competent to
perform neonatal intubation or other resuscitative measures. Each institution is responsible for determining and
documenting level and frequency of competence and qualifications required for someone to assume clinical
responsibility for neonatal resuscitation and related activities. Institutions should provide consistent, frequent
opportunities to maintain clinical competency. For neonatal intubation, frequent opportunities are usually not
forthcoming; therefore, a regionally acceptable substitute for human neonatal intubation practice is recommended.
Simulation and debriefing activities should be used to maintain competency. The commission supports use of new
technologies including use of telehealth educational and simulation activities to assist neonatal resuscitation teams
in maintaining competency.
Neonatal Resuscitation Team
The commission recommends institutions develop a neonatal resuscitation team. A team leader does not need to
be a physician or neonatal nurse practitioner. The commission recommends institutions follow the AAP
guidelines for neonatal resuscitation teams. Nurses involved in newborn care should be appropriately trained to
stabilize infants requiring resuscitation regardless of whether they perform intubation or other advanced
procedures. The commission supports use of telehealth in providing remote expert neonatal resuscitation health
care practitioners to assist in resuscitation efforts, especially in those settings where a physician or neonatal nurse
practitioner is not immediately available.
Supervision
A procedure’s necessity and the nurse’s competency should determine the level of supervision required. Once
competency is determined, general or indirect supervision by a physician or advanced practice nurse with the
scope of practice for neonatal resuscitation and related activities is acceptable.
NCQAC Advisory Opinion 3.0: Neonatal Intubation
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To submit a request, call 1-800-525-0127 (TDD/TTY 711)
Policies, Procedures and Standing Orders
The commission recommends the institution maintain written policies, procedures, standing orders, equipment
and supplies, certification, education and competency validation, risk management, and quality monitoring to
include patient outcomes and required documentation. The commission recommends institutions use CMS
guidance in developing, implementing, evaluating, authenticating, and documenting the use of standing orders.
The Commission recommends continuous contact (direct or remote) with a physician, neonatal nurse practitioner
or pediatric nurse practitioner as soon as possible throughout resuscitation and transport.
Conclusion
The commission concludes that advanced neonatal resuscitation is a highly specialized scope of practice requiring
advanced technical lifesaving skills gained and maintained through continued, frequent performance. RNs may
perform neonatal intubation in emergency or elective situations up to their lawful and individual scope of practice.
References
ASTNA (2010). Advanced Airway Management Position Statement Position Paper:
http://www.astna.org/documents/AdvancedAirwayManagementPositionPaper.pdf
ASTNA. Certified Flight Registered Nurse or Certified Transport RN Program: http://www.astna.org/cfrn_ctrn.html
ASTNA (2012). Qualifications, Orientation, Competencies and Continuing Education for Transport Nurses Position Paper:
http://www.astna.org/documents/Continuing_Education_Rev2012_AB.pdf
AAP/AHA Neonatal Resuscitation Program™: http://www2.aap.org/NRP/
AAP. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients, 3
rd
Edition (G.Woodward, Editor).
Bissinger, R.L. (2012). Neonatal Resuscitation. Medscape: http://emedicine.medscape.com/article/977002-overview
Department of Health and Human Services-CMS (2012). Reform of Hospital and Critical Access Hospital Conditions of
Participation, Rules and Regulations, 77 (95): http://www.cms.gov/REGULATIONS-AND-
GUIDANCE/LEGISLATION/CFCSANDCOPS/DOWNLOADS/CMS-3244-F.PDF
NANN (2010). Neonatal Nursing Transport Standards: Guideline for Practice
Neal, D., Steward, D. and Grant C.C., (2008). Nurse-Led Newborn Resuscitation in an Urban Neonatal Unit. Acta
Paediatrics, 97 (12): 1620-4.
Oregon Health and Science University. Telemedicine Network: http://www.ohsu.edu/xd/health/for-healthcare-
professionals/telemedicine-network/index.cfmhttp://www.ohsu.edu/blogs/doernbecher/2012/08/09/saving-babies-40-miles-
away/
Raghuveer, T.S. and Cox, A.J. (2011). Neonatal Resuscitation: An Update. American Family Physician 83 (8): 911-918:
http://www.aafp.org/afp/2011/0415/p911.html
S.T.A.B.L.E. Program: Post-Resuscitation/Pre-Transport Stabilization Care of Sick Infants, 6
th
Edition:
http://www.stableprogram.org/
Scheans, P. and Rose, L. (2013). Telemedicine for Neonatal Resuscitation: An Innovative Use of Technology. University of
Washington: http://www.nrtrc.org/blog/telemedicine-for-neonatal-resuscitation-an-innovative-use-of-technology/
