2006 OPEN FORUM Abstracts
USING A RAPID TRANSITION PROTOCOL OF INTUBATION-TO-SURFACTANT-TO-NCPAP TO REDUCE INTER-HOSPITAL TRANSPORTS IN NEAR TERM INFANTS WITH RDS
Gordon W. Lassen, RRT-NPS, Stephen D. Minton, MD,
Utah Valley Regional Medical Center, Provo, Utah
Background: Respiratory Distress Syndrome (RDS) continues to be a major cause of increased morbidity and accompanying high cost in the near term infant. RDS often requires transport from community hospitals to a NICU for assisted mechanical ventilation. Two sequential protocols were implemented at a Level II nursery to institute therapy early in the patient's hospital course to improve quality of care and reduce interhospital transfers of these infants.
Methods: Two sequential rapid transition protocols [ 1) Protocol I-Nasal Continuous Positive Airway Pressure (NCPAP) and 2) Protocol II-Surfactant/NCPAP] were developed and approved by the Department of Pediatrics (community hospital) and Division of Neonatology (Level III Center) which targeted infants > 33 weeks gestation with symptomatic RDS. The protocols had specific entrance and failure criteria, pediatrician and staff training, an optimum lung volume strategy, and mandatory Neonatologist consultation at key points along the protocol path. Once entered into the protocol, infants on Protocol I were initially placed on NCPAP (SensorMedics Infant Flow) at 6 cm H20. Infants in Protocol II were intubated, given exogenous surfactant (Curosurf) while on specific conventional ventilation (Bird VIP) settings, immediately extubated, and then placed on NCPAP at 6 cm H20. FiO2, respiratory rate, grunting, retractions, capillary refill time, and blood pressure were assessed pre-intubation and at 30 min, 60 min, and 120 minutes post extubation to monitor patient response. The authors, a newborn nurse educator, and a newborn nurse manager reviewed each patient's medical records for protocol compliance and patient responses. Data were compared from a pre-protocol period from January 1, 2002 to December 31, 2002 (Phase I), the Protocol I period from October 2003 to January 31, 2005 (Phase II), and the Protocol II period from February 1, 2005 to February 28, 2006 (Phase III).
Results: In Phase I there were 2924 births. In retrospect there were 55 patients meeting the protocol entry criteria. 43 (78%) of those meeting the protocol criteria were transported to a Level III NICU. Once admitted to the NICU, the average ventilator days/patient was 2.8. In Phase II, there were 3763 births. 95 patients met the protocol entry criteria. Of these patients 57 patients had NCPAP only, excluding surfactant administration. Of these 57 patients 20 (35%) were transported. In Phase III, there were 2925 births. 108 patients met the protocol entry criteria. All 108 patients received the complete protocol therapeutic regime (intubation-surfactant-NCPAP). 24 (22%) of those patients required transportation. Total ventilator days for the transported patients were 2.8 with a average length of stay of 17.75 days. Comparing inter-hospital transport differences between pre-protocol (2002) data and the fully implemented protocol (2005) data, transports fell from 78% to 22%. The total charge reduction for the community hospital, transport, and the Level III NICU was $1.9 million over the 12 month 2005 period.
Conclusions: Implementing a rapid institution of a surfactant-to-NCPAP protocol in near-term infants with Neonatology consultation is a safe and effective way to reduce neonatal transports, minimize ventilator support and reducing cost. This strategy may also have significant positive results if implemented in larger inborn NICU centers. We believe that a similar protocol may be used in a Level III NICU to reduce ventilator days, reduce ventilator-associated complications and decrease overall operating costs.