371 - A Quality Improvement Project to Decrease Nasal Pressure Injuries in a Neonatal ICU

Poster Number: 371
Publication Number: 371.434

Vikramaditya Dumpa, New York University Long Island School of Medicine, Bronx, NY, United States; Leticia Rios, The Children’s Medical Center at NYU Winthrop Hospital, Springfield gardens, NY, United States; Caterina Tiozzo, NYU-Langone Health, New York, NY, United States; LaShon Pitter, NYU Langone-Long Island, Mineola, NY, United States; Maria Lyn Quintos-Alagheband, NYU Langone Long Island Hospital, Mineola, NY, United States; Maureen Kim, New York University Long Island School of Medicine, Mineola, NY, United States

Background: Early use of non-invasive ventilation (NIV) in neonates decreases the risk of lung injury and is the preferred mode of ventilation even in extremely premature neonates. Preterm infants are at an increased risk of nasal injuries due to the continuous pressure from the interface on their fragile skin. With the increasing use of NIV, the incidence of nasal pressure injuries (PI) in the neonatal intensive care unit (NICU) is estimated to be as high as 60%. These injuries can cause pain, infection, and rarely damage to underlying nasal cartilage leading to nasal deformities. After observing an increased incidence of NIV-related PI in our NICU, we launched a quality improvement project to tackle this problem.

Objective: To decrease the rate of nasal PI by 30% from a baseline of 0.36 injuries/100 NIV days to a goal of 0.25 injuries/100 NIV days by December 2020. The secondary aim is to eliminate any serious harm nasal PI (stage 3 and beyond as per the national pressure injury advisory panel staging).

Design/Methods: An interdisciplinary team was formulated in late 2017 and the collection of data on NIV-related PI and NIV days was started. We conducted a series of plan-do-study-act (PDSA) cycles focused around early detection of injury, change of NIV interface and alternating mask and prongs at the first sign of injury, use of nasal cannulaide as a protective barrier, engagement of both frontline nursing and respiratory therapy staff to do daily skin checks, and increased involvement of wound care nursing.  NIV-related PI rates/100 NIV days were analyzed monthly using run charts (Figure 1).

Results: Through this series of PDSA cycles, we were able to significantly decrease our rate of nasal PI from a baseline of 0.34 from January 2018 to Q2 2019 to 0.24 injuries/100 NIV days by December 2020, with a continued improvement noted in 2021 with a rate of 0.11 injuries/100 NIV days.  There was no serious harm nasal PI after 2019. A spike of events was noted in the second quarter of 2020 during the COVID-19 surge in New York. This increase is likely secondary to the strain on healthcare resources during that time.Conclusion(s): Using quality improvement methodology, we identified opportunities for improvement and instituted measures to decrease nasal PI in neonates. Multidisciplinary collaboration, accessibility to alternative interface(s) if needed, and the use of a barrier between interface and skin are effective strategies to decrease nasal PI in the NICU.
 
Figure 1Run chart showing the nasal PI rates during the study period with the interventions at different time periods. There was a significant centerline shift in the median nasal PI rate from a baseline of 0.34 from Q1 2018-Q2 2019 to 0.18 thereafter. The star denotes the increased incidence during the COVID-19 surge; ACA- Apparent cause analysis, NIV- Non-invasive ventilation, RT- Respiratory therapists