737 - Decreasing Invasive Mechanical Ventilation Days in Premature Infants​

Prolonged invasive mechanical ventilation (IMV) in premature neonates is associated with increased bronchopulmonary dysplasia (BPD), neurodevelopmental impairment, and mortality.  There are no established standards for IMV weaning or specific criteria for extubation readiness in premature infants, leading to significant practice variability among clinicians.  The use of standardized ventilation and weaning protocols in neonatal patients have been demonstrated to reduce days of IMV and lead to improved patient outcomes. 

Objective:

The duration of IMV days in premature infants born less than ≤32 weeks gestation was noted to be higher than the national benchmark at our 97-bed Level IV NICU.  A baseline assessment between 2021 and 2022 (n=29) identified a median duration of 21 IMV days.  This quality improvement project aimed to reduce IMV days in premature infants ≤32 weeks by 10% by February 2023.  

Design/Methods:

A multidisciplinary team represented by neonatologists, neonatal nurse practitioners, nurses and respiratory therapists was assembled.  Barriers to ventilator wean and early extubation were identified (Figure 1).  Multiple plan-do-study-act (PDSA) cycles were completed.  Interventions included: 1) development of an evidence-based clinical practice guideline (CPG) to standardize initial IMV mode, IMV weaning parameters, and extubation criteria for premature infants ≤32 weeks GA at birth; 2) staff education on the CPG; 3) placement of guideline tools at the bedside.  Audits of compliance to the guideline were performed throughout the project. 

Results:

After implementation of the interventions, there was a downward trend in the median IMV days (Figure 2, n=38).  The majority of infants (30/40) were managed in accordance to the IMV CPG recommendations and initial use of volume target ventilation increased (Figure 3).  The overall p</span>roportion of infants with IMV duration >21 days decreased from 48% to 34% (p=0.2).  Time to first extubation attempt decreased from a median of 6 days to 3 days (p=0.02) without a significant increase in the rate of reintubations (38% vs 32%; p=0.6).  BPD of any severity was reduced from 58% to 39% (p=0.6).  Patient demographic characteristics were similar between those of baseline and interventions. 

Conclusion(s):

Implementing a standardized IMV CPG with criteria for weaning and earlier extubation was successful in decreasing total IMV days in infants with ≤32 weeks gestation.