Implementing the Use of Early Lung Recruitment for Newborn Respiratory Management in a Level II Nursery
Abstract
ABSTRACT
Background: Newborn infants experience many physiologic changes at birth to enable transition to extra-uterine life. Newborns are at risk for respiratory distress due to many factors including physiologic immaturity of lungs at birth and illnesses (Reuter, Moser & Baack, 2014). Increased incidence of newborn intensive care unit (NICU) admission for infants of all birth weights was noted at a rate of approximately 64-78 out 1,000 live births by Harrison & Goodman (2015). Increased work of breathing is one of the most common reasons for admission in NICUs (Reuter, Moser, & Baack, 2014). Therefore, with increasing overall respiratory morbidities and increasing NICU admission for infants of all birth weights effective respiratory management for all newborns need to be evaluated.Problem: Infants who display signs of respiratory distress are limited in the method of respiratory support provided at a level II NICU facility. If respiratory support was extended, these infants were transferred to a higher level of service, thus separating mothers from their infants and increasing operational systems costs.Purpose: The purpose of this quality improvement (QI) practice change was to implement an early lung recruitment continuous positive airway pressure (ELR CPAP) protocol to infants greater than 34 weeks gestation in respiratory distress. Specific aims for this practice change was to evaluate if this population would benefit from a ELR CPAP protocol, assess application of the protocol to ensure optimization, to reduce separation of mother from infant, and reduce transfers out of facility.Methods: The Iowa Model was used to guide this QI practice change. The ELR CPAP protocol was brought from a sister hospital for implementation. Interdisciplinary education of staff involved in stabilization and management of infants was completed. Data was collected from similar time-frame in 2017 to be used as comparison for the data collected after implementation of the ELR CPAP protocol in 2018. Outcomes were assessed for Level II Nursery admission rate, transport to higher level of care, and rate of transfer to mother-baby unit after application.Results: Comparison groups were similar size for 2017 (N=112) and 2018 (N=135) and had similar characteristics. There was a reduction of transfers to higher level services by 7%, reduction of admissions to the level II NICU by 6% and an increase of babies transitioned to mother/baby unit by 13%. Furthermore, the average time of birth to transfer to mother/baby unit was decreased by two hours.Discussion: Limitations of this QI project included changes in the organizations documentation process thus leading to complications in retrieving secondary data on some infants. Application of the ELR CPAP was performed through RAM cannula. Literature suggests that the RAM cannula may limit PEEP, therefore effectiveness of PEEP provided may improve with different interface device. The ELR CPAP protocol was provided to 34 weeks gestation and greater who met a respiratory score of 3. Infants with mild respiratory distress whose score did not meet criteria may benefit from application of ELR CPAP.
Background: Newborn infants experience many physiologic changes at birth to enable transition to extra-uterine life. Newborns are at risk for respiratory distress due to many factors including physiologic immaturity of lungs at birth and illnesses (Reuter, Moser & Baack, 2014). Increased incidence of newborn intensive care unit (NICU) admission for infants of all birth weights was noted at a rate of approximately 64-78 out 1,000 live births by Harrison & Goodman (2015). Increased work of breathing is one of the most common reasons for admission in NICUs (Reuter, Moser, & Baack, 2014). Therefore, with increasing overall respiratory morbidities and increasing NICU admission for infants of all birth weights effective respiratory management for all newborns need to be evaluated.Problem: Infants who display signs of respiratory distress are limited in the method of respiratory support provided at a level II NICU facility. If respiratory support was extended, these infants were transferred to a higher level of service, thus separating mothers from their infants and increasing operational systems costs.Purpose: The purpose of this quality improvement (QI) practice change was to implement an early lung recruitment continuous positive airway pressure (ELR CPAP) protocol to infants greater than 34 weeks gestation in respiratory distress. Specific aims for this practice change was to evaluate if this population would benefit from a ELR CPAP protocol, assess application of the protocol to ensure optimization, to reduce separation of mother from infant, and reduce transfers out of facility.Methods: The Iowa Model was used to guide this QI practice change. The ELR CPAP protocol was brought from a sister hospital for implementation. Interdisciplinary education of staff involved in stabilization and management of infants was completed. Data was collected from similar time-frame in 2017 to be used as comparison for the data collected after implementation of the ELR CPAP protocol in 2018. Outcomes were assessed for Level II Nursery admission rate, transport to higher level of care, and rate of transfer to mother-baby unit after application.Results: Comparison groups were similar size for 2017 (N=112) and 2018 (N=135) and had similar characteristics. There was a reduction of transfers to higher level services by 7%, reduction of admissions to the level II NICU by 6% and an increase of babies transitioned to mother/baby unit by 13%. Furthermore, the average time of birth to transfer to mother/baby unit was decreased by two hours.Discussion: Limitations of this QI project included changes in the organizations documentation process thus leading to complications in retrieving secondary data on some infants. Application of the ELR CPAP was performed through RAM cannula. Literature suggests that the RAM cannula may limit PEEP, therefore effectiveness of PEEP provided may improve with different interface device. The ELR CPAP protocol was provided to 34 weeks gestation and greater who met a respiratory score of 3. Infants with mild respiratory distress whose score did not meet criteria may benefit from application of ELR CPAP.