P2D132: Standardizing Management of Patent Ductus Arteriosus in a Regional Neonatal Intensive Care Unit: A Quality Improvement Initiative

Purpose/Objectives: Management of hemodynamically significant patent ductus arteriosus (PDA) includes pharmacotherapy and invasive PDA closure by surgical ligation or transcatheter device closure. In our regional Level IV neonatal intensive care unit, we observed variation in PDA treatment and a high rate of surgical PDA ligation in very low birth weight (VLBW) infants compared to other units in the statewide network (8% versus 1%). The goal of this project was to standardize PDA management within our unit with the overall aim to reduce the surgical PDA ligation rate by 25% in VLBW infants during a six-month period.

Design/Methods: Through several PDSA cycles, we created and implemented a PDA management guideline. Baseline data was collected from one year prior to guideline introduction. All infants with birth weight below 1500 grams were screened for inclusion. Exclusion criteria were death prior to PDA evaluation, pulmonary hypertension as a contraindication to PDA closure, or transfer to our unit for PDA ligation. Adherence to the guideline was tracked by process measures. Balancing measures were rates of bronchopulmonary dysplasia, necrotizing enterocolitis, and transcatheter PDA closure.

Results: During the six-month intervention phase, 23 eligible infants received treatment for PDA. Of these, 22 met the guideline definition of hemodynamically significant PDA. All were treated pharmacologically with recommended medications, but 2 deviated from the guideline in treatment duration. 5 infants underwent surgical ligation and 7 were treated with transcatheter closure. The surgical PDA ligation rate in VLBW infants decreased by 22% from baseline. The transcatheter PDA closure rate and overall mechanical closure rate increased by 44% and 5%, respectively. In VLBW infants treated medically for PDA, the mechanical PDA closure rate decreased by 13%, with a 35% decrease in the surgical ligation rate and a 15% increase in the transcatheter closure rate. There was no significant change in rates of bronchopulmonary dysplasia or necrotizing enterocolitis in VLBW infants.

Conclusion/Discussion: Standardization of PDA management through guideline implementation was feasible in our unit. There was a decrease in the surgical PDA ligation rate and increase in the transcatheter PDA closure rate. While the rate of mechanical closure in all VLBW infants increased, mechanical PDA closure in infants treated medically for PDA decreased, potentially attributable to the efficacy of pharmacotherapy. Continued follow up is needed to see the trends in mechanical PDA closure and the effects of the PDA management guideline on neonatal outcomes.