of the respiratory checklist from July1, April 30, Measures were evaluated monthly. Primary measures:

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1 Surfactant Administration and Respiratory Care During the Golden Hour Adia Stokes MD, Bushra Saleem, MD, Melissa Oh, MD, Natalie Davis, MD and Sara Mola, MD University of Maryland Medical Center Primary author: Adia Stokes, MD, Aims: We aimed to increase the appropriate administration of surfactant in the DR Golden Hour (GH) to eligible VLBW infants from 36% to 70% by January 1 st, Our secondary aim was to examine current DR respiratory management with a checklist (CPAP vs. prophylactic surfactant administration, use of T-piece resuscitator, ETT confirmation) and to monitor for adverse outcomes. Setting: The NICU is one of two Level IV NICUs in the state of Maryland with 43 intensive care beds. There are > 650 admissions/year with about 120 of those admissions being VLBWs. Mechanisms: At initiation, there was no standardized guideline for surfactant administration and notable practice differences among providers. A database review of 2012 revealed that 28 of 77 (36%) of eligible inborn VLBW infants with documented signs and symptoms of RDS (work of breathing, PPV or CPAP requirement, FiO2 requirement >30% in the DR or CXR findings), received their first surfactant dose within the GH. Identifiable barriers included limited accessibility of surfactant, i n c o n s i s tent documentatio n, inconsistent availability of administration materials in the delivery room and variable provider comfort administering surfactant prior to verifying ET tube placement with imaging (Figure 1). Methods: A multidisciplinary group was developed. A standardized guideline for surfactant administration was developed and implemented. Access to surfactant in the Omnicell, previously limited to nurses, was extended to respiratory therapists. A pre-packaged kit was developed with surfactant administration materials and placed in resuscitation areas. Education was provided regarding respiratory goals of the GH and a respiratory checklist was implemented for all inborn VLBW deliveries <32 weeks to help standardize the process (Figure 2). Completion of the checklist in it s entirety by a caregiver was deemed compliant. Measures: All measures were obtained retrospectively, via chart review for a 5 month preintervention period from January 1, 2014 May 31, 2014 and prospectively, postimplementation of the respiratory checklist from July1, April 30, Measures were evaluated monthly. Primary measures: - Percentage of eligible VLBW infants who received surfactant - Percentage of eligible VLBW infants who received surfactant within the GH Secondary measures: - Compliance with the GH respiratory checklist Data/Results: We achieved our aim of improving surfactant administration to VLBW infants within the Golden Hour 70% by January However, there was much noted inconsistency month to month during the initiative. This may be secondary to small patient numbers (Figure 3). There was also inconsistency with completion of the GH respiratory checklist. Interestingly, improved compliance with completing the checklist has been associated with an increase in eligible infants receiving surfactant within the GH (Figure 4). Discussion: Improved compliance with our respiratory checklist is associated with an increase in eligible infants receiving surfactant administration during the GH. We are continuing our QI initiative. Following the data beyond the initial 5-month post-intervention period, we do continue to see a trend toward an increased percentage of eligible infants receiving surfactant within the GH (Figure 2). Team Acknowledgement: Adia Stokes, Bushra Saleem project development, education, data collection and analysis; Melissa Oh data collection and organization, Natalie Davis data analysis and statistician, Sara Mola senior leader

2 Specific change ideas Primary drivers Secondary drivers Guidelines updated, reviewed and posted on shared drive for staff Change Concepts Aim Practice differences among providers No standardized guidelines for surfactant administration Extensive education initiative undertaken for staff Evidence based practice Improve surfactant delivery to eligible VLBW infants within Golden Hour Lack of timely surfactant availability in DR for VLBW deliveries Limited Omnicell access to retrieve surfactant Checklist designed for respiratory management of VLBWs in DR Access achieved for all RT staff & their role to retrieve surfactant for VLBW deliveries was incorporated into checklist Focus on process, roles Inconsistent availability for RT at VLBW deliveries Lack of communication between teams 2 nd huddle enforced during day shift Communication and collaboration Figure 1: Driver Diagram Inconsistent availability of surfactant administration supplies in DR Lack of consistent equipment checks for DR VLBW readiness RT staff encouraged as part of DR team, distributed phone for alert to VLBW deliveries Surfactant administration kit designed and placed in DR Readiness Checklist implemented, L&D liaison performs 2 nd check of DR equipment daily Team building Anticipation and preparation

3 Figure 2: Golden Hour Respiratory Checklist

4 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% N=3 N=6 N=6 N=6 mm m,,m,,m Pre-Intervention Trends in Surfactant Administration N=2 Multidiscplinary GH Education Crossover- No Data N=7 Intervention Initiation Change in RT structure N =6 N= 5 N= 5 N=3 N= 6 Organizational Meeeting w/ RT Leadership N=8 Revision of Checklist Additional Education Jan Feb Mar Apr May June Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr % of VLBWs receiving surfactant within the GH N = total number of VLBWs intubated and receiving surfactant Figure 3: Run Chart demonstrating percentage of eligible infants that received surfactant within the Golden Hour

5 100% Intervention Compliance compared with Surfactant Administration w/in GH 80% 60% 40% Surfactant Compliance 20% 0% July August September October November Figure 4: Compliance with completion of Golden Hour Respiratory Checklist compared to percentage of infants receiving surfactant within the Golden Hour