Evidence-based approach to change in clinical practice: introduction of expanded nasal continuous positive airway pressure use in an intensive care nursery.
OBJECTIVE
Recent studies provide evidence that nasal intermittent positive pressure ventilation (NIPPV) may stabilize the airway of extremely low birth weight infants after endotracheal extubation. The objective of this project was to introduce the use of NIPPV into a busy level 3 intensive care nursery.


METHODS
This report describes the process of NIPPV introduction using a series of rapid-cycle improvement projects, as proposed by the Vermont Oxford Network.


RESULTS
In the first cycle, 7 (88%) of 8 infants were successfully extubated with NIPPV after meeting criteria for reintubation on nasal continuous positive airway pressure alone. Proper positioning of the prongs in the nasopharynx was found to be an important determinant of success. In a second cycle, shorter 2.5-cm nasopharyngeal prongs were more effective than standard 4-cm prongs in 12 recently extubated infants as assessed by objective measurements and subjective nursing reports. A third cycle confirmed the acceptance of this technique in our unit and demonstrated an associated decrease in markers of chronic lung disease in extremely low birth weight infants during the 22 months after its introduction.


CONCLUSIONS
This experience supports the role for the rapid-cycle change model in achieving effective evidence-based medical practices in a neonatal intensive care setting.
Jackson
Jodi K
JK
Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri 64108, USA. jjackson@cmh.edu
Vellucci
Judy
J
Johnson
Patrice
P
Kilbride
Howard W
HW
D003625:Data Collection; D019317:Evidence-Based Medicine; D006801:Humans; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal / Q000458:organization & administration* / Q000592:standards; D015931:Intensive Care, Neonatal / Q000458:organization & administration / Q000592:standards*; D008485:Medical Audit; D009936:Organizational Innovation; D010348:Patient Care Team / Q000458:organization & administration; D011175:Positive-Pressure Respiration / Q000295:instrumentation / Q000379:methods*; D012131:Respiratory Insufficiency / Q000628:therapy*; D018581:Technology Transfer; D017749:Total Quality Management / Q000379:methods; D016896:Treatment Outcome; D015300:Ventilator Weaning