P2C070: Reducing Intubation and Mechanical Ventilation for Very Low Birth Weight Infants Through Optimization of Non-invasive Respiratory Support: A Quality Improvement Initiative

Purpose/Objectives: Preterm infants, especially very low birth weight infants (VLBW), are at increased risk for respiratory distress syndrome due to their lung immaturity and surfactant deficiency. As a result, many VLBW infants are intubated shortly after birth and receive mechanical ventilation. Intubation and mechanical ventilation can contribute to the development of comorbidities in the VLBW population including intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). Thus, avoiding intubation and mechanical ventilation through non-invasive respiratory support in preterm infants may improve outcomes and prevent iatrogenic sequelae. Our project objective is to increase the percentage of infants, born at gestational ages between 25w0d to 29w6d, who are maintained on non-invasive respiratory support from a baseline of 40% to 60% over a 1-year period at a level-4 tertiary care NICU.

Design/Methods: Using the Institute for Healthcare Improvement’s (IHI) Model for Improvement, we implemented interventions aimed at improving the non-invasive respiratory support use for preterm infants in our NICU (figure 1). A retrospective chart review of infants born between 25w0d to 29w6d gestation was conducted from January 2020 to October 2022 to determine the baseline percentage of infants maintained on non-invasive support. A multidisciplinary team including physicians, advanced practice providers, respiratory therapists, hospital leadership, and nursing leadership met, and the process and barriers to using non-invasive support were reviewed with all stakeholders. Several plan-do-study-act (PDSA) cycles targeting these barriers were planned (figure 1). Data is collected monthly from an analysis report generated by the electronic medical record. Statistical process control charts are used to track improvement and annotate the timing of interventions. The primary outcome measures include percentage of infants maintained on non-invasive respiratory support, percentage of infants with BPD, and percentage of infants with IVH. Process measures include percentage of non-invasive surfactant administration and percentage of delivery room intubations. Balancing measures include percentage of pneumothorax and retinopathy of prematurity.

Results: The baseline percentage of infants maintained on non-invasive respiratory support (gestational age 25w0d and 29w6d) was 40%. After the described interventions we have not yet seen special cause variation to shift our mean towards our goal of 60% (figure 2). There was a decrease in the percentage of infants intubated in the delivery room from a baseline of 44% to 38% after the described interventions.

Conclusion/Discussion: Our current interventions have sustained our mean number of infants maintained on non-invasive respiratory support. However, we did see a decrease in the percentage of delivery room intubations from the baseline. As we continue to track our post-intervention data and implement more process-based interventions, we expect to see an increase in the mean number of infants maintained on respiratory support. Our anticipated improvement in maintaining infants on non-invasive support will hopefully lead to reduced incidence of IVH and BPD in our unit.