KEYWORDS: Chest compressions, epinephrine, pneumothorax, Apgar <4

Transcription

1 Improving Delivery Room Management of Very Low Birth Weight Infants Amaris Keiser MD, Angela Montgomery MD, Matthew Bizzarro MD, Yeisid Gozzo MD and the Delivery Room Initiative Committee University School of Medicine, New Haven, CT, USA Primary author: Amaris Keiser, MD (23) KEYWORDS: Chest compressions, epinephrine, pneumothorax, Apgar <4 Background: Effective delivery room (DR) resuscitation and stabilization of very low birth weight (VLBW; <15 grams) infants is known to impact short and long-term outcomes. Compared to VON benchmark data, we noted an increased incidence of chest compressions, epinephrine administration and low Apgar scores during DR resuscitations of VLBWs at our institution. We also noted increased rates of pneumothoraces. This was attributed to ineffective troubleshooting to establish ventilation, and lack of strict adherence to NRP guidelines. Aims: To decrease the incidence of DR chest compressions from 13.4% to 5.4%, epinephrine administration from 4.6% to 3.1%, Apgar of <4 at 5 minutes from 14.4% to 1.5% and pneumothorax from 6.7% to 4.7% to meet the VON 5 th for each measure. We will achieve this within one year and sustain it indefinitely. Setting: A Level IV, 54 bed NICU (Type C) at an urban academic medical center with approximately 8 admissions per year (88% inborn). VLBWs account for approximately 18% of annual admissions. Mechanisms/Drivers of Change: In the past, the process for the DR resuscitation of VLBW infants was provider-dependent, without cohesive guidelines to inform medical management or consensus on how the resuscitation should proceed. Therefore, a multidisciplinary committee was formed to review DR practices and to devise evidence-based guidelines for care. The committee identified lack of clearly-defined DR roles and responsibilities, variable preparation for impending deliveries, and lack of routine assessment of provider resuscitation skills as potential drivers of elevated rates of undesirable outcomes (Figure 1). Methods: We created formal management guidelines, a preparation checklist and toolbox for VLBW deliveries, a Roles and Responsibilities chart, and conducted universal staff NRP supplemental education with a focus on establishing effective ventilation. We expanded the role of the Respiratory Therapist (RT) during the resuscitation, established standardized settings for the use of the T-piece resuscitator (TPR), and held RT-led universal training and skills validation sessions demonstrating the use of the TPR. Measures: Measures were collected via chart review and presented at committee meetings biannually. Outcome measures: Percent of VLBWs receiving chest compressions in the DR Percent of VLBWs receiving epinephrine in the DR Percent of VLBWs with Apgar score <4 at 5 minutes Percent of VLBWs with pneumothorax Data/Results: Following implementation of our QI initiative, there was an absolute reduction in the incidence of chest compressions by 9.3% (Figure 2a) and epinephrine use by 3.1% (Figure 2b) during DR resuscitations. There was a decrease in the incidence of Apgar score of <4 by 9.8% (Figure 2c), and pneumothorax by 2.7% (Figure 2d). While most outcome measures decreased to at or below the VON 5 th following QI implementation, only the differences between chest compressions and Apgar score <4 were statistically significant (Table 1, Figure 3). Discussion: Our data demonstrate that we achieved the aim of decreasing rates of DR compressions, epinephrine administration and low Apgar scores to below the 5 th of VON benchmark data. Although there was a substantial decrease in the rate of pneumothorax, it did not reach the VON 5 th, likely due to small numbers. Data collection is ongoing. Next phase outcome measures will assess the impact of the Golden Hour Initiative on the incidence of hypoglycemia, hypothermia, timing of surfactant and antibiotic administration, and family awareness of the transition from DR to NICU. We will then assess the impact of our initiatives on the incidence of long-term sequelae of prematurity, specifically rates of intraventricular hemorrhage, bronchopulmonary dysplasia and retinopathy of prematurity.

2 Team Acknowledgement: Angela Montgomery, MD: involved in identification of potential drivers, development of educational materials, development of implementation strategies, responsible for data collection and analysis Amaris Keiser, MD: prepared abstract, assisted with data collection, collation and analysis Yeisid Gozzo, MD: senior leader, head of Delivery Room Initiative Committee (DRIC), provided structure and oversight for all aspects of this project, provided ongoing support for this project Matthew Bizzarro, MD: senior leader, identified need to address poorly performing outcome measures, created DRIC, provided ongoing support for this project Delivery Room Initiative Committee Members: Angela Craft, APRN Tracy Gambardella, PA-C Nancy Koval, APRN Louise Dunphy, RN Timothy Mack, RT Involved in the identification of potential drivers of change, creation of interventions, implementation of initiative, and ongoing education/training

3 Key Driver Diagram Figure 1: Key Driver Diagram further delineating the mechanisms used in the development of this QI project

4 Percent of VLBWs Percent of VLBWs (A) Incidence of DR Chest Compressions 3 25 Formation of DRIC, literature/practice review and planning of staged implementation NRP knowledge pre-tests collected, knowledge gaps identified; Indtroduction to DRIC/Goals, DR checklist and review of NRP with focus on effective ventialtion (MRSOPA) 2 Preliminary data with decreased chest compressions/epinephrine use 15 VON 5th 1 "Roles & Responsibilities" chart 5 Time Period (B) Incidence of DR Epinephrine Administration NRP knowledge pretests collected, knowledge gaps identified Introduction to DRIC/Goals, DR checklist and review of NRP with focus on effective ventilation (MRSOPA) Formation of DRIC, literature/practice review and planning of staged implementation Preliminary data with decreased chest compressions/epinephrine use 6 Roles & Responsibilities chart VON 5th 4 2 Time period

5 Percent of VLBWs Percent of VLBWs (C) Incidence of Apgar Score <4 at 5 minutes NRP knowledge pretests collected, knowledge gaps identified Introduction to DRIC/Goals, DR checklist and review of NRP with focus on effective ventilation (MRSOPA) 35 3 Preliminary data with decreased chest compressions/epinephrine use Formation of DRIC, literature/practice review and planning of staged implementation "Roles and Responsiblities" chart VON 5th 1 5 Time Period (D) Incidence of Pneumothorax Formation of DRIC Literature/practice review Planning of staged implementation NRP knowledge pretests collected, knowledge gaps identified Introduction to DRIC/Goals, DR checklist and review of NRP with focus on effective ventilation (MRSOPA) 8 6 VON 5th 4 2 Preliminary data with decreased chest compressions/epinephrine use "Roles & Responsibilities" chart Time Period

6 Figures 2 A-D: (A): Run chart demonstrating a statistically significant decrease in the incidence of chest compressions following implementation of this QI initiative. (B): Run chart demonstrating a trend towards a decrease in the rate of epinephrine use following implementation of this QI initiative. (C): Run chart demonstrating a statistically significant decrease in the incidence of low Apgar scores following implementation of this QI initiative. (D): Run chart demonstrating a trend towards a decrease in the incidence of pneumothorax following implementation of this QI initiative. Pre- Implementation (-) Post- Implementation (-) VON 5 th () P-value Absolute Reduction Relative Reduction Incidence of DR Chest Compressions Incidence of DR Epinephrine Incidence of Apgar score <4 at 5 minutes Incidence of DR Pneumothorax 13.4% 3.5% 5.4%.1* 9.3% 74% 4.6% 1.8% 2.8% % 6% 14.4% 6.6% 9.6%.5* 9.8% 54% 6.7% 4.6% 4.6% % 31% Table 1: Table showing pre and post-implementation data on the four outcome measures; figures are derived from the average incidence over the specified time period. Of note, the differences in rates of chest compressions and Apgar scores <4 were statistically significant * * DR Compressions DR Epinephrine Apgar < 4 Pneumothorax Pre-implementation (-) Post-implementation (-) Figure 3: Graphical representation of pre and post implementation data for the four selected outcome measures

7 Improving Delivery Room Management of VLBW Infants AIMS Primary Drivers Secondary Drivers Overall Project Goal To improve the delivery room management of VLBW infants to optimize infant outcomes Primary Aim: To decrease the incidence of chest compressions and epinephrine use during DR resuscitations of VLBWs, as well as decrease the incidence of low Apgar scores and pneumothorax to at or below the VON 5 th benchmark data within 1 year Outcome Measures: Percent of inborn VLBW infants who receive chest compressions or epinephrine in the DR, are assigned an Apgar score of <4 at 5 minutes, or develop pneumothorax Balancing Measures 1) Delivery room mortality 2) Incidence of IVH 3) Incidence of Pneumothorax Failure to consistently establish effective ventilation A) Lack of effective communication between team members B) Failure to establish a shared mental model Lack of standardized approach to the resuscitation of VLBW infants Inadequate preparation for impending VLBW deliveries No opportunity for feedback/learning/growth/improvement following resuscitation Failure to thoroughly troubleshoot prior to moving to the next intervention No standardized teaching or maintenance of skills requirement outside of required NRP certification for providers involved in resuscitations of VLBWs Lack of standardized process to identify and establish roles and responsibilities during the resuscitation of VLBWs Inconsistent use of the T-piece resuscitator and use of variable settings Limited/unclear role of the Respiratory Therapist Lack of standard set-up of the warmer and equipment prior to deliveries Lack of standard equipment check prior to deliveries All necessary supplies and equipment not reliably available at time of delivery Specific clinical information about impending delivery often unknown No process in place for post-resuscitation review Potential Change Concepts 1) Reinforce the NRP algorithm to all NICU providers with a specific focus on establishing effective ventilation 2) Assure adherence to NRP guidelines through biannual skills validation sessions and mock codes 3) Mount NRP algorithm in the DR for easy reference 1) Creation of Roles and Responsibilities chart 2) Creation of nametags with assigned roles for use during resuscitations 3) Primary roles (team leader, airway, back-up airway) determined at morning huddle and written on whiteboard in DR 1) Unit-wide transition from selfinflating bag to T-piece resuscitator 2) Universal training of ALL medical providers for the use of TPR, led by RT 3) Establishment of standard settings and guidelines for TPR use at ALL VLBW deliveries 4) Reinforcement of effective TPR use through biannual skills validation sessions for ALL medical providers 1) Creation of preparation checklist 2) Creation of VLBW toolbox 3) One team member designated to obtain clinically-relevant information from OB and convey to DR team 1) Mandatory debriefing sessions following VLBW resuscitations 2) Quarterly newsletter updates