title: NICU bedside caregivers sustain process improvement and decrease incidence of bronchopulmonary dysplasia in infants < 30 weeks gestation.
abstract: BACKGROUND
  The objective of this study was to investigate whether a respiratory care bundle, implemented through participation in the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2005) and primarily dependent on bedside caregivers, resulted in sustained decrease in the incidence of bronchopulmonary dysplasia (BPD) in infants < 30 wk gestation.
  
  
  METHODS
  A retrospective cohort study was conducted. Infants inborn between 23 wk and 29 wk + 6 d of gestation were included. Patients with congenital heart disease, significant congenital or lung anomalies, or death before intubation were excluded. Four time periods (T1-T4) were identified: T1: September 1, 2002 to August 31, 2004; T2: September 1, 2004 to August 31, 2006; T3: September 1, 2006 to August 31, 2008; T4: September 1, 2008 to August 31, 2010.
  
  
  RESULTS
  A total of 1,050 infants were included in the study. BPD decreased significantly in T3 post-implementation of the respiratory bundle compared with T1 (29.9% vs 51.2%, respectively; adjusted odds ratio [aOR] = 0.06 [95% CI 0.03-0.13], P = < .001). The decrease was not sustained into T4. There was a significant increase in the rate of BPD-free survival to discharge in T3 compared with T1 (53.1% vs 47%; aOR = 1.68 [95% CI 1.11-2.56], P = .01) that was also not sustained. The rate of infants requiring O2 at 28 d of life decreased significantly in T3 versus T1 (40.3% vs 69.9%, respectively; aOR = 0.12 [95% CI 0.07-0.20], P = < .001). Increases in the rate of surfactant administration by 1 h of life and rate of caffeine use were observed in T4 versus T1, respectively. There was a significant decrease in median ventilator days and a significant increase in the median number of noninvasive CPAP days throughout the study period.
  
  
  CONCLUSIONS
  In this study, implementation of a respiratory bundle managed primarily by nurses and respiratory therapists was successful in increasing the use of less invasive respiratory support in a consistent manner among very low birthweight infants at a single institution. However, this study and others have failed to show sustained improvement in the incidence of BPD despite sustained process change.
authors.affiliation: Department of Pediatrics, Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland smola@peds.umaryland.edu.
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Mola
authors.affiliation: Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, College of Medicine, Charleston, South Carolina.
authors.forename: David J
authors.initials: DJ
authors.lastname: Annibale
authors.affiliation: Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, College of Medicine, Charleston, South Carolina.
authors.forename: Carol L
authors.initials: CL
authors.lastname: Wagner
authors.affiliation: Department of Pediatrics, Medical University of South Carolina College of Medicine, Charleston, South Carolina.
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Hulsey
authors.affiliation: Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, College of Medicine, Charleston, South Carolina.
authors.forename: Sarah N
authors.initials: SN
authors.lastname: Taylor
mesh_terms: D001997:Bronchopulmonary Dysplasia / Q000453:epidemiology / Q000628:therapy*; D017028:Caregivers; D005260:Female; D005865:Gestational Age; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal; D008297:Male; D019095:Point-of-Care Systems; D011663:Pulmonary Surfactants / Q000627:therapeutic use*; D012121:Respiration, Artificial / Q000379:methods*; D012189:Retrospective Studies; D013997:Time Factors; D014481:United States / Q000453:epidemiology
chemical_list: D011663:Pulmonary Surfactants
keywords: NICU; bedside caregiver; bronchopulmonary dysplasia; mechanical ventilation; prematurity; very low birthweight