Herrick Heidi M, Weinberg Danielle D, James Jennifer, Murray Ashley, Brown-Jackson Loretta, Chaudhary Aasma, Posencheg Michael A, Foglia Elizabeth E
Department of Pediatrics, Division of Neonatology, The Hospital of the University of Pennsylvania, Philadelphia, Pa.
Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pa.
Pediatr Qual Saf. 2022 Aug 1;7(4):e580. doi: 10.1097/pq9.0000000000000580. eCollection 2022 Jul-Aug.
Despite recommendations promoting noninvasive delivery room (DR) ventilation, local historical preterm DR noninvasive ventilation rates were low (50%-64%). Project aims were to improve DR noninvasive ventilation rate in very low birth weight (VLBW) neonates (<1500 g) with a focus on decreasing DR intubations for ineffective positive pressure ventilation (PPV).
We addressed drivers for improving noninvasive ventilation and decreasing intubations for ineffective PPV through plan-do-study-act cycles. Outcome measures were intubation for ineffective PPV (defined as intubation for heart rate <100 despite ongoing PPV) and final respiratory support in the DR. Our process measure was adherence to division-wide DR-intubation guidelines. Balancing measures were maximum FiO and hypothermia. We analyzed data using statistical process control charts and special cause variation rules.
There were 139 DR intubations among 521 VLBW neonates between January 2015 and February 2020. The noninvasive ventilation rate upon intensive care nursery admission was higher than historically reported at 73% and sustained throughout the project. The intubation rate for ineffective PPV was 10% and did not change. The number of VLBW neonates between intubations for ineffective PPV increased from 6.1 to 8.0. Ten intubations did not comply with guidelines. Balancing measures were unaffected.
Noninvasive ventilation rates were higher than historically reported and remained high. After plan-do-study-act cycles, the number of VLBW neonates between intubations for ineffective PPV increased without impacting balancing measures. Our data demonstrate that effective ventilation (heart rate > 100) using noninvasive support is possible in up to 90% of VLBW infants but requires ongoing PPV training.
尽管有建议提倡在产房（DR）进行无创通气，但当地历史上早产产房无创通气率较低（50%-64%）。项目目标是提高极低出生体重（VLBW，<1500克）新生儿在产房的无创通气率，重点是减少因无效正压通气（PPV）而进行的产房插管。
我们通过计划-执行-研究-行动循环来解决改善无创通气和减少因无效PPV而插管的驱动因素。结果指标是因无效PPV而插管（定义为尽管持续进行PPV但心率<100时插管）以及产房的最终呼吸支持。我们的过程指标是遵守科室范围内的产房插管指南。平衡指标是最大吸氧浓度（FiO）和体温过低。我们使用统计过程控制图和特殊原因变异规则分析数据。
2015年1月至2020年2月期间，521例VLBW新生儿中有139例在产房插管。重症监护病房入院时的无创通气率高于历史报告的73%，且在整个项目期间保持稳定。因无效PPV而插管的比例为10%，没有变化。两次因无效PPV而插管之间的VLBW新生儿数量从6.1增加到8.0。有10次插管不符合指南。平衡指标未受影响。
无创通气率高于历史报告且保持在较高水平。经过计划-执行-研究-行动循环后，两次因无效PPV而插管之间的VLBW新生儿数量增加，且未影响平衡指标。我们的数据表明，高达90%的VLBW婴儿使用无创支持进行有效通气（心率>100）是可能的，但需要持续的PPV培训。
