The Impact of Standardized Respiratory Care Practices on Delivery Room Intubation Frequency and NICU Ventilator Days in VLBW Infants: A Quality Improvement Initiative

Abstract

Objective

Chronic lung disease (CLD) is a common morbidity affecting very low birth weight (VLBW) infants, and exposure to mechanical ventilation in this population is a well-known risk factor. Our 2018 Vermont Oxford Network outcome report demonstrated an increase in the incidence of CLD from 2017 (15%) to 2018 (30.9%).

Study Design

In response, we convened a multidisciplinary team to review our practices. Starting with baseline data on our delivery room (DR) and initial ventilation practices, we developed a key driver diagram to guide change ideas. We implemented sequential interventions using Plan-Do-Study-Act (PDSA) cycles.

Results

From January 2017 through January 2022, 390 infants with birthweights < 1,500 g were admitted to our level IV NICU. Special cause variation was observed in our two-outcome metrics: percent of inborn VLBW infants intubated in the DR, lowering the center line from 44 to 18% and lowering the center line from 19 to 12 total ventilation days per 100 patient days in this same population.

Conclusion

Implementing standardized respiratory care practices resulted in significantly decreasing DR intubation rates and total ventilation days in this vulnerable population.

Key Points

• Employing protective lung strategies in VLBW infants is effective in limiting lung injury and preventing the development of chronic lung disease.

• Implementation of a resuscitation bundle can improve standard processes in the delivery room.

• Prophylactic surfactant replacement continues to be practiced in neonatal units.

Keywords

very low birth weight infant - delivery room intubation - ventilation days - surfactant - pneumothorax

• References

• 1 Subramaniam P, Ho JJ, Davis PG. Prophylactic nasal continuous positive airway pressure for preventing morbidity and mortality in very preterm infants. Cochrane Database Syst Rev 2016; (06) CD001243
• 2 Jobe AH, Ikegami M. Mechanisms initiating lung injury in the preterm. Early Hum Dev 1998; 53 (01) 81-94
• 3 Polin RA, Carlo WA. Committee on Fetus and Newborn, American Academy of Pediatrics. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics 2014; 133 (01) 156-163
• 4 Soll RF. Prophylactic natural surfactant extract for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2000; 1997 (02) CD000511
• 5 Soll RF, Morley CJ. Prophylactic versus selective use of surfactant for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2000; (02) CD000510
• 6 Dunn MS, Kaempf J, de Klerk A. et al; Vermont Oxford Network DRM Study Group. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011; 128 (05) e1069-e1076
• 7 Abman SH, Collaco JM, Shepherd EG. et al; Bronchopulmonary Dysplasia Collaborative. Interdisciplinary care of children with severe bronchopulmonary dysplasia. J Pediatr 2017; 181: 12-28.e1
• 8 Kakkilaya V, Jubran I, Mashruwala V. et al. Quality improvement project to decrease delivery room intubations in preterm infants. Pediatrics 2019; 143 (02) 143
• 9 Finer NN, Carlo WA, Walsh MC. et al; SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010; 362 (21) 1970-1979
• 10 Dylag AM, Tulloch J, Paul KE, Meyers JM. A quality improvement initiative to reduce bronchopulmonary dysplasia in a level 4 NICU-golden hour management of respiratory distress syndrome in preterm newborns. Children (Basel) 2021; 8 (04) 301
• 11 Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB. COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008; 358 (07) 700-708