BACKGROUND
Prolonged invasive mechanical ventilation in preterm infants is associated with the development of bronchopulmonary dysplasia (BPD). Barotrauma, volutrauma, and free radical injury disrupt alveolar integrity, leading to fibrosis and simplification of lung architecture. Lung protective strategies, such as decreasing the duration of invasive ventilation by timely weaning and early extubation, have been shown to decrease the risk of BPD.
OBJECTIVE
Our SMART aim was to reduce the duration of invasive ventilation by 30% before Dec 2020 by: (a) weaning invasive ventilator settings within 1 hour of "wean-able" blood gases, and (b) extubating within 1 hour of any acceptable blood gas obtained while on "extubate-able" ventilator settings.
DESIGN
Cohen Children's Medical Center and North Shore University Hospital are regional perinatal centers that admit > 3000 VLBW infants annually. Our target population included infants born at < 32 weeks gestation and < 1500 g birth weight who were intubated in the first week. "Acceptable" blood gases were defined as pH >7.20 and pCO2 45-50 mmHg. "Extubatable" ventilator settings were defined for both conventional and high frequency ventilation. Barriers to timely ventilator weaning and extubation were identified and interventions targeted to address key drivers of change. PDSA cycles included: establishing blood gas and extubation criteria, educating NICU staff, engaging a multidisciplinary BPD prevention team, developing a process for rapid notification of medical staff about all blood gas results, and reviewing and disseminating data monthly. As a balancing measure, we tracked the incidence of re-intubation.
RESULTS
Extubations within 1 hour of meeting criteria increased from a median of 64% to 88% after dissemination of the practice guidelines and a robust educational program for NICU providers (Fig. 1A). Median time from meeting criteria to extubation decreased from 325 minutes to 49 minutes (Fig. 1B), and the median duration of intubation decreased from 8 days to 3 days (Fig. 2). However, the proportion of ventilator weans occurring within 1 hour of a qualifying blood gas remained unchanged at 50%. Time to weaning was variable, with a median of 88 minutes. There was no change in re-intubation rates.
CONCLUSION
Standardization of practice and intensive instruction of providers by a multidisciplinary team led to decreased duration of invasive mechanical ventilation. It is likely that providers were responsive to shortening the time to extubation because that is perceived as urgent, with intuitive impact on BPD. In contrast, it has remained difficult to improve weaning times, possibly because of entrenched practice, unit workflow (rounds, shift change), and the relative frequency of blood gases. Based on data since Oct 2020, it is possible that system changes (e.g., rapid notification of providers for blood gas results, BPD nursing champion program) are facilitating culture change.
