647 - Less Invasive Surfactant Administration in the Delivery Room - A Single Center Quality Improvement Initiative

Less invasive surfactant administration (LISA) has been shown to reduce morbidity and mortality for treatment of respiratory distress syndrome (RDS). We describe a single center quality improvement (QI) strategy to implement LISA in our level IV neonatal intensive care unit (NICU) and subsequently implement LISA in the delivery room with the goal to reduce the need for mechanical ventilation.

Objective: A SMART aim was developed with the goal to implement LISA in >30% of eligible infants by 12/31/2020 and extend to delivery room implementation by 12/31/2021.

Design/Methods:

Eligibility criteria were spontaneously breathing inborn infants >25 weeks’ gestational age with clinical signs of RDS who were not enrolled in a surfactant research trial prohibiting LISA. Primary and secondary drivers were identified to generate change ideas for 3 PDSA cycles. Outcome measures included LISA success rate, ventilator days, and percent of infants never intubated. Balancing measures included failed LISA procedures, adverse LISA events, intubation within 12 hours post LISA, and/or need for repeat surfactant therapy. Statistical process control charts were generated and analyses performed using QI methodology to assess progress and special cause variation over time.

Results: From 2020 to 2022, a total of 116 patients received LISA with 38 receiving LISA in the delivery room. The mean gestational age and birth weight were 31 weeks and 1627 grams. Overall 98% of LISA procedures were successful without need for conversion to intubation or adverse events. Overall 87% of infants receiving LISA avoided intubation post LISA (Table 1). Special cause variation was detected with a sustained decrease in average ventilator days (10.9 to 7.5) after LISA implementation (Figure 1). The moving range decreased (not shown). We observed a sustained increase in infants 28-32 weeks’ gestation never requiring intubation (39.4 to 50.7%) (Figure 2A). The number of infants requiring repeat surfactant therapy decreased (47 to 29%) (Figure 2B).

Conclusion(s):

Our quality improvement science approach for implementing LISA within a level IV NICU with systematic education and methodology reduced the need for mechanical ventilation and repeat surfactant therapy for infants with RDS. We have established an innovative framework for delivery room LISA as a part of neonatal resuscitation in infants with RDS that can be disseminated and implemented in other NICUs. To our knowledge, this initiative provides the first protocolized approach to prophylactic surfactant via LISA in the delivery room as a part of neonatal resuscitation in infants with RDS.