A Quality Improvement Project to Standardize Surfactant Delivery in the Era of Noninvasive Ventilation

INTRODUCTION: Continuous positive airway pressure (CPAP) and surfactant both improve outcomes for premature infants with respiratory distress syndrome. However, prolonged trials of CPAP, as well as observation periods after intubation, may delay the administration of surfactant. Late surfactant treatment likely increases the incidence of bronchopulmonary dysplasia, which leads to significant morbidity and healthcare utilization. METHODS: We aimed to decrease time from meeting standard criteria (start of a continuous run of F(i)O(2) > 40% or P(a)CO(2) > 65 for >90 min) to intubation, and from intubation to surfactant administration, for infants <1,500 g or younger than 32 weeks gestation. Retrospective data collection from the electronic medical record assessed those process measures as the primary endpoints. Balancing measures were the adverse outcomes of asymmetric lung disease, the inappropriate position of the endotracheal tube, or pneumothorax on the first x-ray (within 24 h) after surfactant. RESULTS: Mean time to intubation for infants 28–32 weeks gestation decreased from 321 to 81 minutes in response to a literature review for physicians and free-text orders for notification. Time to intubation for infants younger than 28 weeks gestation did not change. Administration of surfactant within 1 hour of intubation improved from 78% to 100% after a program for trainees and coordination with radiology. There were no adverse occurrences. CONCLUSIONS: Educational interventions and targeted process change can successfully implement standard criteria for intubation and surfactant administration for premature infants. Determination of an acceptable range of evidence-based practice is essential for the engagement of medical staff. Timely intubation and surfactant may decrease bronchopulmonary dysplasia.