Quality Improvement Approaches to BPD Jay P. Goldsmith, M.D. Tulane University New Orleans, Louisiana goldsmith.jay@gmail.com
No conflicts of interest to declare
There is nothing more dangerous to the preterm lung than an anxious physician with an endotracheal tube and bag A. Jobe, 2006
Columbia Avery ME et al, 1987
% Cases Variation in Practice and Outcomes Babies Hospital vs. Boston Mechanical Ventilation, NCPAP and Chronic Lung Disease in 80 70 60 50 40 30 20 10 0 VLBW Infants Mech Vent NCPAP Surf CLD Babies Boston Van Marter et al, Pediatrics, 2000
Decreasing BPD is Multifactorial Prematurity (VLBW and ELBW infants) Maternal steroid administration Golden Hour care; early surfactant (?) Early surfactant administration or avoid intubation; increase ncpap use and success Low tidal volume ventilation: decrease volu-barotrauma Nutrition/fluids/oxygen and PDA management Vitamin A/caffeine Preventing infection
Strategies to Prevent BPD Proven from RCTs Caffeine Vitamin A Postnatal steroids Volume targeted ventilation Equivocal evidence from clinical trials Antenatal steroids Exogenous surfactant Early PDA closure High frequency ventilation Non-invasive ventilatory support Inhaled ino Reduced oxygen exposure
Strategies to Prevent BPD Proven from RCTs Caffeine Vitamin A Postnatal steroids Volume targeted ventilation Equivocal evidence from clinical trials Antenatal steroids Exogenous surfactant Early PDA closure High frequency ventilation Non-invasive ventilatory support Inhaled ino Reduced oxygen exposure
A Cluster Randomized Controlled Trial.to Reduce the Incidence of Survival Free of Bronchopulmonary Dysplasia Walsh M et al, NICHD Group, Pediatrics 2007 17 NICHD centers 3 model centers with best BPD free survival rates; other 14 randomized to QI(I) or not (C) 4093 babies followed in 14 centers 27 PBPs in 3 domain areas: DR care, vent practices, nutrition and fluids Intervention centers chose 5-13 PBPs (median 7) Rates of BPD survival not significantly changed!!
VON Quality Improvement Collaborative (NIC/Q 2002-03) Payne, et al: Pediatrics, 2006: 118; S73-7 Development and early implementation of PBPs to reduce chronic lung disease; team approach 16 participating institutions ( Breathsavers ) 16 PBPs developed Each institution implemented an average of 5 PBPs (range 2-9) 12 of 15 institutions improved CLD rate or percentile ranking Improvement for entire cohort (~1800 patients/yr x 2 years) = 27% reduction in BPD!!!!
Chronic Lung Disease (VON 2001-3) 40 35 30 25 20 15 10 5 0 Coll VON 2001 2003
Breathsavers: % CLD by Center (VON 2001-3) 70 60 50 2001 2003 40 30 20 10 0 C1 C2 C5 C6 C7 C10 C13 C15 C18 C20 C25 C28 C29 C35 C37 C38
Observations, Not Science ( Observational science ) The incidence of BPD slowly decreased over the last decade but now has leveled off The institutions that have the most aggressive use of ncpap have the lowest BPD incidence The successful implementation of a single PBP in respiratory care may not result in a decrease in the BPD rate The institutions with the highest rates of BPD had the largest declines in incidence when doing effective QI
Potentially Better Practices to Decrease BPD (VON Toolkit) Promote ncpap Reduce unplanned extubations Minimize duration of CMV Limit VAPs Promote Golden Hour Care Administer Vitamin A to infants <1000 gms Use gentle ventilation techniques Oxygen targeting Administer caffeine
The successful implementation of a single PBP in respiratory care may not result in a decrease in the BPD rate Vent days CPAP days 500 450 400 350 300 250 200 150 100 50 0 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Center 4: ET Go Home Group
Reducing Unplanned Extubations Measure # unplanned extubations (numerator) over 100 ventilator days (denominator) Determine when unplanned extubations occur (e.g weighing, suctioning, etc.) Design and test techniques for reducing unplanned extubations Measure results and modify techniques accordingly Lesson: QI requires metrics and PDSA cycles
A Model Annotated Run Chart Loughead JL et al., Jt Comm J Qual and Pt Safety, 2008
Implementing 5 PBP Respiratory Practices on Outcomes and Cost Levesque BM et al. Pediatrics, 2011 60 infants, 26-326/7 weeks gestation (retrospective controls)- 1 institution 5 PBPs: bcpap, bcpap in DR, intubation criteria, extubation criteria, prolonged CPAP to avoid oxygen Results: BPD decreased from 17% to 8% (p =.27); costs for equipment and surfactant were lower
Implementing 5 PBP Respiratory Practices on Outcomes and Cost Levesque BM et al. Pediatrics, 2011 Retrospective cohort (n = 61) Study Group (n = 60) P value Intubation in 1 st 72 hours 52% 11% <.0001 Surfactant use 48% 14% <.001 Days on oxygen 23.5 +/-44.5 9.3 +/- 22 =.04 Mechanical ventilation days 8.8 +/- 27.8 2.2 +/- 6.2 =.005 Hypotension 33% 15% =.03
Observations, Not Science ( Observational science ) The long term effects of BPD may be more related to pco2 levels at 36 weeks than the need for oxygen It is easier to reduce BPD on the larger VLBW infants (1000-1500 gms) The need for oxygen (which determines the incidence of BPD by the NIH definition) may be manipulated by acceptance of lower sats, use of pressure without oxygen, use of diuretics and other meds, altitude
It is easier to decrease BPD in larger, more mature premies Birenbaum, et al, Pediatrics, 2009
The need for oxygen (which determines the incidence of BPD by the NIH definition) may be manipulated by acceptance of lower sats, use of pressure without oxygen, use of diuretics and other meds, altitude Walsh et al. Pediatrics, 2004
Columbia Experience Ammari et al, J Pediatr 2005;147:341 Gestational Age 23-25 wks N = 87 26-28 wks N = 106 29-31 wks N = 54 DR Intubation DR CPAP 72 hours - CPAP Failure CPAP Success 31% 69% 38% 31% 5% 95% 17% 78% 0% 100% 7% 93%
Issues in CPAP implementation COIN and DRM trials show no advantage to DR implementation of ncpap Miss opportunity to give early surfactant Selection of correct patients critical to success Concern over chin strap, especially in children receiving enteral feeds Developmental and device injury concerns Lesson: There is no free lunch!!
Chow L et al, Pediatrics, 2003
Hours AVIOX Trial: All Centers All subjects/monitoring periods with modifiable SpO 2 2500 2000 Median SpO 2 95% (91%, 97%) 37% 1500 1000 Centers varied: 16-64% 48% Above In Range Below 500 15% 0 65 70 75 80 85 90 95 100 SpO 2 (%) Hagedorn et al, 2007
Oxygen Targeting: It Takes a Team Effort Seymour ( see-more )
Implementing Potentially Better Practices Self assessment Comparison to other units, standards, expected outcomes Determine need for improvement and get consensus Develop strategy; write or adopt PBP Get buy in from all stakeholders Make it positive, fun, rewarding
Does QI Improvement Last Over the Long Term? Payne NR et al: Pediatrics, 2010 9 year retrospective study of 8 NICUs who participated in ReLi group QIC from 1998-2001 Analyzed data in same units in 2006 Retrospective cohort analysis of 4065 VLBW infants
Does QI Improvement Last Over the Long Term? Payne NR et al: Pediatrics, 2010 2001 2006 P value Delivery room intubation 70% 52% <.001 Conventional ventilation 75% 62% <.001 Postnatal steroids 35% 10% <.001 Use of ncpap 57% 78% <.001 BPD free survival 68% 66%.16 BPD rate 25% 29%.017 Survival to discharge 90% 93% <.001 Nosocomial infections 18% 15%.045
Why QI (PBP) Doesn t Work Outcomes multifactorial Wrong PBP to improve outcome PBP not implemented effectively Inadequate teaching or preparation Poor staff compliance Team not working together or not involved Inadequate or delayed feedback Loss of interest Too many alligators in the swamp!!!!!!
What have we learned? QI requires commitment and creativity of a multidisciplinary team; must have cooperation of full NICU staff Multi-institutional database essential for identifying areas in need of improvement May be successful in implementing PBP and not effect ultimate goal (decrease incidence of BPD) Metrics (annotated run charts) essential to success of program Pick 2 or 3 PBPs and do them well Culture and feel of unit will change (less ventilators, more CPAP, alarm frequency, etc.) Decreasing variation in practice improves outcomes
Quality Improvement: not easy, but worth the effort!!