clinical safety & effectiveness cohort # 16 implementation...
TRANSCRIPT
Clinical Safety & Effectiveness Cohort # 16
Implementation of T-Piece Resuscitator (Neopuff) in
University Hospital NICU
DATE
Background
• ~10% neonates require resuscitative efforts at birth
• Positive Pressure Ventilation (PPV) is key to successful resuscitation
- Positive pressure support should be commenced
at 30-60sec
Newborn Resuscitation Algorithm
3 John Kattwinkel et al. Pediatrics 2010;126:e1400-e1413
Choice of Device for PPV
• Depends on availability of gas supply
• Skills of resuscitator
• Desire to deliver pressures:
- Peak inspiratory pressures (PIP)
- Positive end expiratory pressures (PEEP)
Basics of Positive Pressure Support
Ideally, PPV should be given with PEEP
• More rapid acquisition of functional residual
capacity
• Improved oxygenation and lung compliance
• Decreased lung injury
Effect of PEEP on Alveolar Volume
Without PEEP With PEEP
www.derangedphysiology.com/php/Respiratory-failure-and-mechanical-ventilation
Use of Positive Pressure Support
• International guidelines state that PEEP is likely to be
beneficial in stabilization of preterm neonates
–76% of units use PEEP
Resuscitation Devices
1. Anesthetic Rebreathing Bag
(Current standard of care at UH)
2. Self-Inflating Bag
(Standard of care in some NICUs)
3. T-Piece Resuscitator (Neopuff)
(Proposed standard of care at UH)
T-Piece Resuscitator (Neopuff)
• Intrinsically provides PEEP
• Delivers more accurate and consistent PIP
• Produces more effective tidal exchange than bag-
and-mask systems
10
Does PPV affect subsequent neonatal outcomes?
PPV “Double Edge Sword”
– Too high of pressure
• Over-distention
• Increase risk of PTX & PIE
• Histological injury to lungs
– Too low of pressure
• Decrease HR
• Chest compressions
• Intubation
Recommendation by NRP
• According to the American Academy of Pediatrics /
Neonatal Resuscitation Program (NRP) Guidelines
• The T-piece resuscitator should be used during DR
neonatal resuscitation
Quality Improvement Cycle
www.resultsresults.co.uk
AIM Statement
To implement the use of Neopuff in the delivery
room for resuscitation of preterm infants in NICU
from 0 % to 50 % by
May 20th, 2015
16
Project Milestones
• Team Created January 2015
• AIM statement created January 2015
• Weekly Team Meetings Feb 2015
• Background Data, Brainstorm Sessions, Feb 2015
Workflow and Fishbone Analyses
• Interventions Implemented March 2015
• Data Analysis March-May 2015
• CS&E Presentation June 5, 2015
17
Ishikawa Diagram
18
PLAN: Intervention
• Met with stakeholders and reviewed the literature
about the use Neopuff; clarified the concerns of the
providers
• 5 Neopuff machines were ordered by the
department of Pediatrics, Neonatology division
• Planned on the use of Neopuff for PPV according to
the neonatal resuscitation guidelines
PLAN: Intervention
Education of the health care providers:
• Developed the checklist and protocol for the use of Neopuff
• Respiratory therapist did in-service for all the nurses
Organized hand on experience on the use of Neopuff for
residents, NP’s, fellows and attendings
• Had weekly NICU tours and answered the questions about
the use of Neopuff
• Had meeting with OB-team and clarified their concerns
DO: Implementing the Change
Started the use of Neopuff on March 1st, 2015
Encountered problems:
• Missing patient supplies
• Reminders for HCP’s
• Technical issues
• Follow up on overnight admissions
• Monthly meetings / Journal club discussion
CHECK: Results/Impact
• Reviewed all the charts of babies less than 32 weeks
gestational age and required PPV in the DR
• Pre intervention group 28 patients
• Post intervention group 11 patients
• Relatively more premature babies in Neopuff group
CHECK: Results/Impact
• Neonatal outcomes:
Apgar scores at 1 & 5 mins, DR intubations,
RDS, pneumothorax, PIE, mechanical ventilation days in
first week, IVH > grade 2, hydrocephalus
• Developed check list for data extraction
• Data were collected from chart reviews over a three month
period: Dec, Jan and Feb 2015
UCL 12.01
12.91
CL 5.18
5.73
0
2
4
6
8
10
12
14
12/3
/1
4 5
:0
5 A
M
12/6
/1
4 1
2:0
0 A
M
12/1
2/14
12
:00
A
M
12/1
8/14
11
:06
A
M
12/1
8/14
1:4
7 P
M
12/2
1/14
7:5
8 A
M
12/3
0/14
3:1
6 P
M
12/3
0/14
6:1
5 P
M
1/6/15
9
:36
P
M
1/10
/1
5 5
:3
7 P
M
1/12
/1
5 9
:1
4 P
M
1/15
/1
5 1
2:5
8 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
7 P
M
1/15
/1
5 1
1:2
2 P
M
1/23
/1
5 6
:0
7 A
M
1/24
/1
5 2
:2
2 A
M
1/24
/1
5 2
:2
4 A
M
1/25
/1
5 4
:1
6 A
M
1/28
/1
5 2
:0
8 P
M
1/31
/1
5 1
2:1
1 A
M
2/8/15
1
:32
P
M
2/15
/1
5 7
:2
5 A
M
2/17
/1
5 7
:1
9 A
M
2/22
/1
5 9
:2
2 A
M
2/25
/1
5 2
:4
6 A
M
2/27
/1
5 2
:5
7 A
M
3/7/15
5
:39
P
M
3/9/15
5
:59
P
M
3/10
/1
5 1
1:2
1 P
M
3/14
/1
5 2
:1
2 P
M
3/16
/1
5 8
:3
6 A
M
4/2/15
2
:25
A
M
4/4/15
8
:42
A
M
4/19
/1
5 1
1:3
0 A
M
4/27
/1
5 1
1:1
3 A
M
5/7/15
1
2:0
0 A
M
5/10
/1
5 1
2:0
0 A
M
Ap
ga
r sc
ore
s at 1
m
in
Date of Birth
Apgar scores at 1 min
Pre and Post Neopuff
UCL 15.05 15.22
CL 7.07 7.18
0
2
4
6
8
10
12
14
16
12/3
/1
4 5
:0
5 A
M
12/6
/1
4 1
2:0
0 A
M
12/1
2/14
12
:00
A
M
12/1
8/14
11
:06
A
M
12/1
8/14
1:4
7 P
M
12/2
1/14
7:5
8 A
M
12/3
0/14
3:1
6 P
M
12/3
0/14
6:1
5 P
M
1/6/15
9
:36
P
M
1/10
/1
5 5
:3
7 P
M
1/12
/1
5 9
:1
4 P
M
1/15
/1
5 1
2:5
8 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
7 P
M
1/15
/1
5 1
1:2
2 P
M
1/23
/1
5 6
:0
7 A
M
1/24
/1
5 2
:2
2 A
M
1/24
/1
5 2
:2
4 A
M
1/25
/1
5 4
:1
6 A
M
1/28
/1
5 2
:0
8 P
M
1/31
/1
5 1
2:1
1 A
M
2/8/15
1
:32
P
M
2/15
/1
5 7
:2
5 A
M
2/17
/1
5 7
:1
9 A
M
2/22
/1
5 9
:2
2 A
M
2/25
/1
5 2
:4
6 A
M
2/27
/1
5 2
:5
7 A
M
3/7/15
5
:39
P
M
3/9/15
5
:59
P
M
3/10
/1
5 1
1:2
1 P
M
3/14
/1
5 2
:1
2 P
M
3/16
/1
5 8
:3
6 A
M
4/2/15
2
:25
A
M
4/4/15
8
:42
A
M
4/19
/1
5 1
1:3
0 A
M
4/27
/1
5 1
1:1
3 A
M
5/7/15
1
2:0
0 A
M
5/10
/1
5 1
2:0
0 A
M
Ap
ga
r sc
ore
s at 5
m
in
s
Date of Birth
Apgar scores at 5 mins
Pre and Post Neopuff
UCL 7.66
4.87
CL 2.71
1.36
0
1
2
3
4
5
6
7
8
9
12/3
/1
4 5
:0
5 A
M
12/6
/1
4 1
2:0
0 A
M
12/1
2/14
12
:00
A
M
12/1
8/14
11
:06
A
M
12/1
8/14
1:4
7 P
M
12/2
1/14
7:5
8 A
M
12/3
0/14
3:1
6 P
M
12/3
0/14
6:1
5 P
M
1/6/15
9
:36
P
M
1/10
/1
5 5
:3
7 P
M
1/12
/1
5 9
:1
4 P
M
1/15
/1
5 1
2:5
8 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
7 P
M
1/15
/1
5 1
1:2
2 P
M
1/23
/1
5 6
:0
7 A
M
1/24
/1
5 2
:2
2 A
M
1/24
/1
5 2
:2
4 A
M
1/25
/1
5 4
:1
6 A
M
1/28
/1
5 2
:0
8 P
M
1/31
/1
5 1
2:1
1 A
M
2/8/15
1
:32
P
M
2/15
/1
5 7
:2
5 A
M
2/17
/1
5 7
:1
9 A
M
2/22
/1
5 9
:2
2 A
M
2/25
/1
5 2
:4
6 A
M
2/27
/1
5 2
:5
7 A
M
3/7/15
5
:39
P
M
3/9/15
5
:59
P
M
3/10
/1
5 1
1:2
1 P
M
3/14
/1
5 2
:1
2 P
M
3/16
/1
5 8
:3
6 A
M
4/2/15
2
:25
A
M
4/4/15
8
:42
A
M
4/19
/1
5 1
1:3
0 A
M
4/27
/1
5 1
1:1
3 A
M
5/7/15
1
2:0
0 A
M
5/10
/1
5 1
2:0
0 A
M
Me
ch
an
ic
al ve
ntilatio
n d
ays in
first w
ee
k
Date of Birth
Mechanical ventilation days in first week
Pre and Post Neopuff
0 10 20 30 40 50 60 70 80 90
DR Intubation
Surfactant
RDS
PIE
Pnuemothorax
IVH > Grade 2
Hydrocephalus
Neonatal Outcomes in Pre and Post
Neopuff
Post
Pre
UCL 6.96
6.61
CL 2.36 2.18
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
12/3
/1
4 5
:0
5 A
M
12/6
/1
4 1
2:0
0 A
M
12/1
2/14
12
:00
A
M
12/1
8/14
11
:06
A
M
12/1
8/14
1:4
7 P
M
12/2
1/14
7:5
8 A
M
12/3
0/14
3:1
6 P
M
12/3
0/14
6:1
5 P
M
1/6/15
9
:36
P
M
1/10
/1
5 5
:3
7 P
M
1/12
/1
5 9
:1
4 P
M
1/15
/1
5 1
2:5
8 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
6 P
M
1/15
/1
5 7
:5
7 P
M
1/15
/1
5 1
1:2
2 P
M
1/23
/1
5 6
:0
7 A
M
1/24
/1
5 2
:2
2 A
M
1/24
/1
5 2
:2
4 A
M
1/25
/1
5 4
:1
6 A
M
1/28
/1
5 2
:0
8 P
M
1/31
/1
5 1
2:1
1 A
M
2/8/15
1
:32
P
M
2/15
/1
5 7
:2
5 A
M
2/17
/1
5 7
:1
9 A
M
2/22
/1
5 9
:2
2 A
M
2/25
/1
5 2
:4
6 A
M
2/27
/1
5 2
:5
7 A
M
3/7/15
5
:39
P
M
3/9/15
5
:59
P
M
3/10
/1
5 1
1:2
1 P
M
3/14
/1
5 2
:1
2 P
M
3/16
/1
5 8
:3
6 A
M
4/2/15
2
:25
A
M
4/4/15
8
:42
A
M
4/19
/1
5 1
1:3
0 A
M
4/27
/1
5 1
1:1
3 A
M
5/7/15
1
2:0
0 A
M
5/10
/1
5 1
2:0
0 A
M
# o
f 7
P
ossib
le
Date of Birth
Combined Neonatal Outcomes
Pre and Post Neopuff
ACT: Sustaining the Results
• The use of Neopuff was 100 % in the DR
• DR use of Neopuff guidelines, will be a part of NICU manual
• In-service will be provided to new employees (residents,
NNP’s and fellows during NICU orientation
• Respiratory therapist structured note will be embedded in
the EMR which will help in the data extraction
• Every month the data will be analyzed and discussed in the
NICU QI meeting
29
Return on Investment (ROI)
• In NICU we do “Bundle Billing” on the basis of the
severity of illness and not on the basis of individual
problems list like Pneumothorax, IVH etc. That is why it
is difficult to determine ROI
• It will be interesting to look at the Length of stay (LOS)
and will determine the ROI; but most of the babies in
post-intervention group are still in-house
Return on Investment (ROI)
• What will be the LOS in babies with hydrocephalus
and further neurodevelopmental outcomes ?
• Days on mechanical ventilation is associated with
Bronchopulmonary Dysplasia (BPD); need to know
how many babies develop BPD at the time of
discharge ?
30
31
Conclusion/What’s Next
We observed that in the post-intervention group
• The Apgar scores were improved or not worsened
• Babies stayed on the mechanical ventilator for less number of days
• Less number of babies developed PIE, Pneumothorax, IVH grade 2 and Hydrocephalus
• RDS and intubation rate were higher in those babies; that may be due to being more immature ?
The Team
–Syed Shah, MD
– Irene Sandate, NP
–Rachel Rivas, RN
–Rachael Farner, RN
–Eric Larson, RT
–Karen Aufdemorte, Facilitator
–Amy Quinn, MD
–Margarita Vasquez, MD
–Donald C McCurnin, MD
–Steven R Seidner, MD
Sponsor Department: Department of Pediatrics, Neonatology Division
33
34
Thank you!
Questions ? Comments….
Anesthetic Rebreathing Bag
• Delivered pressure and tidal volume depend on how hard bag is squeezed
–Pressure-limiting valve
–Manometer
• PEEP delivered by controlling rate of gas escaping from back of bag during expiration
Self-Inflating Bag (SIB)
• Depends on flow of air or O2
• Peak pressure dependent on operator
–Valve limits maximum pressure delivered
T-Piece Resuscitator (TPR) (Neopuff)
• Requires continuous gas supply to
generate set peak pressure and set PEEP
• Two ports attach to TPR
–One port goes to oxygen (green tubing)
–One port goes to patient (white tubing)
Literature Evidence
• Compared PPV during DR resuscitation in neonates with
Neopuff (40 pts) and self-inflating bag (50 pts)
• The duration of PPV in delivery room was significantly less in
Neopuff group (p < 0.001)
• A fewer neonates required DR intubation in Neopuff group
(p = 0.04)
• In the Neopuff group, a higher proportion of neonates
resuscitated with room air only (p = 0.001)
Anup Thakur et al, T-piece or self inflating bag for positive pressure ventilation during delivery room
resuscitation: An RCT. Resuscitation 90 (2015) 21–24
Literature Evidence
• Studied 31 operators using a Neopuff, a self-inflating bag
and a flow-inflating bag during 30 s of ventilation on a
neonatal manikin
• Compared the delivery of consistent PIP of 20 or 40 cm of
cm H2 O and a PEEP of 5 cmH2 O
• The Neopuff delivered the desired pressures more
accurately than the two other devices
Stacie Bennett et al. A comparison of three neonatal resuscitation devices. Resuscitation 67 ; 2005