Aim: Reduction in the rate of CLD in ELBW infants (<1000 grams) by 30% from its baseline of 72 % by January 2016.

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1 LIVE (Less Invasive Ventilation of ELBW infants) HEALTHY WVU Children s Hospital, Morgantown, WV, USA Rebecca Tilley, RN; Jamie Karr, RT; Tiffany Blosser, RN; Christy Dixon, RT; Melinda Connolly, ANP; Autumn Keiffer, MD, Sanjay Mitra, MD (smitra@hsc.wvu.edu) Aim: Reduction in the rate of CLD in ELBW infants (<1000 grams) by 30% from its baseline of 72 % by January Setting: The NICU at WVU Children s hospital provides neonatal care of Level IV as defined by new perinatal guidelines. It is 43 beds NICU and almost 600 infants are admitted in a year, of those approximately 40 to 50 infants are extremely low birth weight (ELBW) infants. Mechanisms: Retrospective data of two years suggested that 72% of (ELBW) infants had chronic lung disease (CLD) at 36 weeks corrected gestational age. Regardless of the increased use of continuous positive airway pressure (CPAP) at our center in last two years, CLD rate at our center remained above 3 quartile probably due to inconsistency in potential better practices (PBPs) known to minimize lung injury in ELBW during the initial period of life. PBPs of stabilization on CPAP in the delivery room or within two hours of birth after INSURE method, and permissive hypercapnia to facilitate earlier extubation of ELBW infants placed on mechanical ventilator were identified as key areas of improvement. Methods: Guidelines, algorithm and process map for early CPAP, INSURE and permissive hypercania towards less invasive ventilator management strategies have been created. Process of initiating bubble CPAP in the delivery room was standardized and simulated. Video of simulated process and computer based learning module was created for education of the staff. Goals of each process measure are created to achieve primary aim of reduction in the CLD rate by 30% from its baseline. Measures: Percentage of infants placed on CPAP in the delivery room, percentage of infants maintained on CPAP for at least 3 days (35% baseline, with the goal of 60%), ventilation days (baseline; mean ventilation days of 29.5), use of surfactant/ 50 ELBW infants (baseline; 1.74/patient), and rate of pneumothorax (balance measure). Flow sheet to monitor and measure processes have been created for review on a monthly basis and go through cycle of PDSA. Data/Results: Total of 14 ELBW infants were born in our center, since implementation of guidelines of which 6 (42%) were placed on CPAP in the delivery room and only 2/6 (33%) was maintained consistently on CPAP for three days. Discussion: This is the initial phase of our quality improvement initiative and we are trying to figure out the ways to enter the data and monitor the process measures and compliance. We identified two potential areas of improvement, which are briefing and assigning role of team members at the delivery time, and education of the respiratory therapists in setting up of bubble CPAP to improve upon stabilization of ELBW infants on CPAP in the delivery room. We believe that standardized LIVE approach will help us reducing ventilation days and dependence on oxygen at 36 weeks gestation age. Which will result in sending infants home early to their families with less complicated care and better health outcomes.

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4 Name: MRN: DOB: DR Management for infants <1000 gms PRE DELIVERY AND DR SET UP: Done Not done If not done, Why? Antenatal consult Not medically indicated Other Antenatal Betamethasone Exposure Not medically indicated Other Bubble CPAP set up in DR Not medically indicated Other Surfactant brought to the DR Not medically indicated Other DELIVERY: (Time of Birth: ) Done Not done If not done, Why? Stabilized on Bubble CPAP in DR Not medically indicated Not ready Other Surfactant given in DR Not medically indicated Not available» Maximum PIP in DR» PEEP in DR» FiO2 in DR NICU: Time of arrival to POD ON Bubble CPAP at one hour of life Yes No Not medically indicated Intubated Other Chin Strap applied Yes No Other Line placed within one hour (type) Yes No Not medically indicated Type Sodium Acetate Yes No Not medically indicated Other Caffeine Initiated Yes No Not medically indicated Other» CPAP level» FiO2 LIVE HEALTHY 72 hour flow sheet initiated Yes No Completed ETT card at bedside Yes No DR & NICU Initial Management Team Attending: NNP/Fellow: RN in DR: Fellow: Resp Therapist: RN in NICU:

5 DOL #2 Date: DOL #3 Date: DOL #4 Date: DOL #5 Date: DOL #6 Date: Check if Ventilator Check if Ventilator Check if Ventilator Check if Ventilator Check if Ventilator changes made to: changes made to: changes made to: changes made to: changes made to: Mode Mode Mode Mode Mode Vt Vt Vt Vt Vt PEEP PEEP PEEP PEEP PEEP Rate Rate Rate Rate Rate I time I time I time I time I time TCO2 value TCO2 ON TCO2 ON TCO2 ON TCO2 ON Extubated? Extubated? Extubated? Extubated? Extubated? Time Time Time Time Time N/A N/A N/A N/A N/A Redosed Changes per: Changes per: Changes per: Changes per: Changes per: DOL #7 Date: DOL #8 Date: DOL #9 Date: DOL #10 Date: Extubation: Check if Ventilator Check if Ventilator Check if Ventilator Check if Ventilator changes made to: changes made to: changes made to: changes made to: Mode Mode Mode Mode Vt Vt Vt Vt PEEP PEEP PEEP PEEP Rate Rate Rate Rate I time I time I time I time TCO2 ON TCO2 ON TCO2 ON TCO2 ON Extubated? Extubated? Extubated? Extubated? Time Time Time Time N/A N/A N/A N/A Changes per: Changes per: Changes per: Changes per: Caffeine given 2 hours prior to extubation? Yes No