383 - Quality Improvement Initiative: The Impact of Multi-Level Standardized Respiratory Care Practices on Intubation and Ventilator Days in VLBW Infants

Poster Number: 383
Publication Number: 383.434

Poonam Thakore, University of Connecticut, Hartford, CT, United States; Bette Ford, Gwinnett Neonatology, Atlanta, GA, United States; Jamille Rancourt, Connecticut Children's Medical Center, Hartford, CT, United States; Lenora Codrington-Ennis, New York University Grossman School of Medicine, Brooklyn, NY, United States; Jill Herr, Connecticut Children's Medical Center, WEst Hartford, CT, United States; Andrew Lietz, Connecticut Childrens, Bolton, CT, United States; Steven Low, Connecticut Children's Medical Center, Hartford, CT, United States; Sandra Motta, Connecticut Children's, Hartford, CT, United States; Lindsay J. Tucker, Connecticut Children's Medical Center, Carver, MA, United States; Kendall Johnson, Connecticut Children's Medical Center, Hartford, CT, United States; Annmarie Golioto, Connecticut Children's, Hartford, CT, United States

Background: Protective lung strategies in Very Low Birth Weight (VLBW) infants are effective in limiting lung injury and preventing the development of chronic lung disease. Initial management with nasal continuous positive airway pressure (nCPAP) has been shown to be an acceptable alternative to initial intubation and prophylactic surfactant in spontaneously breathing preterm infants.

Objective: Decrease the rate of the inborn delivery room (DR) intubation in the VLBW infant by 15% within 12 months and reduce the total number of ventilation days in the VLBW by 10% within 12 months.

Design/Methods: Our multidisciplinary team reviewed baseline data on delivery room and initial ventilation practices to develop a key driver diagram and targets for change [Image1]. We implemented change interventions using Plan-Do-Study-Act (PDSA) cycles. Statistical p and x control charts were used to monitor interventions in real-time.

Results: Special cause variation was observed following implementation of a standard pathway for stabilizing the VLBW infant in the DR lowering the control line from 47% to 29.8% and then further, to a baseline of 17.6% [Image 2, Chart 1]. Gestational age (GA) subgroup analyses show a decrease in DR intubation rates reaching significance in infants born at ≤25 weeks and ≥28 weeks [Image 2, Chart 2]. As a balancing measure, we examined the rate of development of early pneumothorax and the incidence of hypothermia on admission ( < 36.4 ℃). There were no significant differences in the incidence of pneumothorax in infants in the CPAP stabilized group (1/107 vs 5/105, p-value 0.117). Infants placed on immediate nCPAP did not have an increased incidence of hypothermia on admission (2/107 vs 2/103 infants). Special cause variation was observed in ventilation days per month in inborn VLBW infants after PDSA cycles 1-5, lowering the control line from 69 to 47 days [Image 3, Chart 3]. GA subgroup analyses show a decrease in median ventilation days in all GA groups [Image 3, Chart 4].Conclusion(s): Implementing multi-level standardized respiratory care practices resulted in our ability to stabilize VLBW infants on nCPAP in the DR, significantly decreasing DR intubation rate, exposure to early mechanical ventilation, and total ventilation days. Continued work will focus on earlier surfactant administration for the infants intubated in the DR, monitoring of balancing measures, and adherence to early ventilation strategy algorithms to further impact ventilation days.
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