Increasing Use of Waveform Capnography for Neonates During Interfacility Transport

Purpose/Objectives: Waveform capnography (WC) is a non-invasive approximation of the arterial partial pressure of carbon dioxide. Literature supports the use of WC in an intensive care setting to confirm correct advanced airway placement, continuously monitor carbon dioxide levels, assess the effectiveness of chest compressions, and identify the return of spontaneous circulation during resuscitation. Despite these benefits, WC is still not common practice in NICUs or interfacility neonatal transports. In 2017, the GAMUT Quality Improvement Collaborative launched a quality improvement project to increase the use of WC in patients with advanced airways during transport; Cincinnati Children’s participated. We report our center’s experience with increasing uptake of WC use during transport from March 2017 to December 2020.

Design/Methods: Our SMART aim was to increase the WC use of qualifying neonates during transport from 50% to 75%. A Key Drivers of Change diagram was developed, and interventions were determined (Figure 1). Interventions were selected for levels of reliability supporting a failure rate of no more than 1 out of 100 transports. These were implemented using the Model for Improvement’s Plan-Do-Study-Act (PDSA) cycles. After the first year, statistical process control (SPC) charts were used to track compliance, signal system changes, and facilitate a better understanding of barriers to and enablers of improvement.

Results: Our initial baseline WC utilization rate for neonates with advanced airways during transport was 50%. At the end of the PDSA1 cycle (Interventions: the creation of WC improvement team, the addition of WC tubing to the ventilator, and educational drive), the WC utilization rate was 80%. The WC utilization rates at the end of subsequent PDSA cycles during the project’s first year were 89% (PDSA2) and 92% (PDSA3). (Figure 2). The following two years’ WC utilization rates were 90% (2019) and 92% (2020). There was only one advanced airway dislodgement on transport during the study period.

Conclusion/Discussion: We exceeded project expectations and safely sustained a greater than 90% utilization rate for WC use in qualifying neonates. Adopting WC use in neonates was a cultural challenge because this is not yet standard practice in many NICUs. Our belief is that the benefits of WC use to the safe management of pediatric and adult patients are the same in our neonatal population. The adoption of WC use for neonates on transport has even driven the use of it in our local NICUs. We demonstrated that quality improvement methodology can be used to drive the use of WC in neonates on transport with advanced airways, and we strongly encourage others to consider adding it to the way they monitor neonatal ventilation and advanced airway positioning.