Infants born at less than 32 weeks of gestation have a much higher chance of survival now in comparison with several decades ago. In addition, infants born prematurely are at a higher risk for needing mechanical ventilation and oxygen supplementation due to immature lung development. Unfortunately, prolonged periods of oxygen use and mechanical ventilation can damage lung tissue and contribute to a condition known as bronchopulmonary dysplasia (BPD).1 As the survival rate for extremely low-birth-weight (ELBW) infants increases, the incidence of BPD has increased to greater than 40% on average.2 Within our institution, the 2018 rate for BPD in infants born less than 33 weeks of gestation is 38.2%. Research indicates that utilizing continuous positive pressure ventilation instead of invasive mechanical ventilation can decrease BPD by as much as 17%.1 Therefore, redesigning our approach to respiratory support in infants less than 32 weeks of gestation was imperative to decrease the incidence of BPD and improve long-term outcomes and success for our infants.
By way of a quality improvement (QI) training "boot camp," a multidisciplinary team from the neonatal intensive care unit, including physicians, nurse practitioners, nurses, respiratory therapists, pharmacists, and quality/safety specialists, was tasked with decreasing the use of invasive mechanical ventilation in ELBW infants and increasing the use and success with early noninvasive positive pressure ventilation support. The "boot camp" was a 5-month training course that covered the basics of QI and supported the team through the journey of designing and implementing a QI project under the guidance of QI experts from within the institution.
The scope of the project was focused on infants born less than 32 weeks of gestation, and the team was tasked with developing respiratory care guidelines for early extubation and successful maintenance of infants on noninvasive support. The outcome measure for the project was first-time extubation success rate as defined as remaining extubated for greater than 7 days on the first attempt. To monitor for improvement, process and balancing measures were determined. These included measuring adherence to the guideline (or compliance with extubation criteria), placement of an extubation order in the electronic medical record at the time of extubation (allowing monitoring of extubation success), and monitoring for pressure injuries with increased use of noninvasive respiratory support.
By way of learning and practicing QI methodology, the team was able to systematically implement guidelines for respiratory care in this identified group of premature infants. Guidelines were established using literature review and expert consensus. Guidelines included standards for extubation readiness, utilization of the appropriate type of noninvasive ventilation by gestational age, and slow and methodical weaning of the noninvasive ventilation. By extubating infants earlier and decreasing the time they are invasively ventilated, there may be less alveolar damage and thus, decreased risk of developing BPD.3,4 Unfortunately, the optimal type of noninvasive support is not well established in the literature. In the literature, the general theme is that ELBW infants have a higher success of remaining extubated if placed on noninvasive positive pressure ventilation using an occlusive interface, such as the Fisher & Paykel interface, which is used at our institution.5-9 Respiratory support delivered via other types of nonocclusive devices has been shown to deliver significantly less pressure and provide less effective carbon dioxide elimination.10,11
During 3 of the last 4 months, we have seen greater than 80% first-time extubation success, which was our original goal. In addition, there have been noted cultural changes within our neonatal intensive care unit's acceptance of early extubation, increasing use of the Fisher & Paykel interface, and increased dedication to successful maintenance on noninvasive ventilation. While increased dedication and use of the Fisher & Paykel interface is a key component of extubation success, it has likely been a contributing factor to our increasing pressure injuries for infants less than 32 weeks of gestation. Staff are highly motivated to keep the infants extubated. Because of the complexity of the interface setup and difficulty in finding the best fit for our ELBW infants, we have unfortunately experienced stage 3 and stage 4 reportable septal and nasal pressure injuries as a result. Staff have been provided continuous education and hands-on training to help ensure that the interface is applied properly. The unit is also actively recruiting staff nurses and respiratory therapists to train as superusers and assist with fit and troubleshooting each shift. This is a key step in the successful maintenance of noninvasive support and decreasing the incidence of reintubation and pressure injuries.
In conclusion, the QI boot camp was deemed to be successful by the participating team. Team members reported an increased understanding of QI methodology as well as demonstrated application of the methodology to this project. Careful and thoughtful planning allowed the team to evaluate changes that were needed at each step of the implementation in order to ensure success. As we see more success with higher gestational age infants, we become more willing to extubate lower gestational age infants with more fragile skin and more severe lung disease, which initially may increase our failure rate as we figure out the unique challenges of supporting the smallest and youngest babies without a breathing tube. In addition, further investigation into the challenges of implementing and maintaining the Fisher & Paykel interface is warranted as ongoing success may be limited by outside factors not discussed here, such as nurse staffing ratios and skin protection strategies.
-Jaclyn Archer, MSN, RN
-Lisa M. Steurer, PhD, RN, CPNP-PC, CPN
St. Louis Children's Hospital
St. Louis, Missouri
-Gillian Pet, MD, MSCI
Washington University School of Medicine
St. Louis, Missouri
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