37 An improvement project to lower pneumothorax in neonates born at ≥36 weeks gestational age

Background Nasal continuous positive airway pressure (nCPAP) use has improved outcomes in premature neonates. The efficacy of nCPAP in term babies is debatable. Our institutional observed – expected (O-E) data showed that we had high pneumothorax rates in term babies supported in the delivery room (DR) with nCPAP.Objective To test the hypothesis that quality improvement (QI) efforts to reduce nCPAP in the DR would reduce pneumothorax rates.Methods We performed interventions to change nCPAP use in the DR to optimize nCPAP use with interdisciplinary DR team. We focused on reserving nCPAP for infants remaining hypoxemic on free flow oxygen rather than for signs of high work of breathing and/or the need for ANY supplemental oxygen in neonates born at 36 weeks of gestation or greater. We assessed continuous positive airway pressure (CPAP) use in the DR and pneumothorax events in deliveries between pneumothorax before and after the algorithm was implemented. We used statistical process control charts to assess improvement.Results CPAP utilization in the delivery room for infants >36 weeks decreased from 3.4% to 1.0% ( figure 1). Frequency of pneumothorax decreased (figure 2), with births between pneumothorax events increasing from 293 to 530 (figure 3).Conclusion A reduction in the use of CPAP in DR was associated with a decrease in the rate of pneumothorax with no increase in neonates with respiratory distress.Abstract 37 Figure 1Percent chart shows the process measure assessing utilization of CPAPs in the delivery room. The baseline was extended after August 17, and special cause was then detected twice related to interventions (see annotations) lowering the mean to 2.1% and then to 0.5%. Abbreviations: CPAP, continuous positive airway pressure; LCL, lower control limit; NRP, Neonatal Resuscitation Program; UCL, upper control limitAbstract 37 Figure 2Vermont Oxford network data highlighting an elevated rate of pneumothorax. Observed to expected pneumothorax and rate of pneumothorax among Neonatal Intensive Care Unite (NICU) admissions in term neonates > 37 weeks gestation. Pneumothorax rates as a function of NICU admissions decreased substantially from 2016 to 2019, while the observed – expected (0-E) rates decreased from approximately 8 in 2016 to approximately 2 in 2018 and then less than zero from 2019–2021Abstract 37 Figure 3Geometric chart assessing the outcome measure of births between pneumothorax events