Use of High-fidelity Simulation to Drive Quality Improvement: Implementation of Bubble CPAP (BCPAP) in the Neonatal Resuscitation Room

Purpose/Objectives: Bubble continuous positive airway pressure (BCPAP) with use of occlusive nasal interfaces, such as nasal masks (flexitrunk) or short binasal prongs, allow for optimal PEEP and are beneficial in reducing chronic lung disease (CLD) of prematurity. Our NICU has previously utilized RAM cannula in the delivery room (DR) for premature infants that are not requiring intubation and mechanical ventilation. We started a quality improvement (QI) initiative to decrease our rates of CLD of prematurity. One aim was to begin use of BCPAP with the appropriate interface immediately upon arrival to the DR. Simulation was performed to optimize this process and limit failures when utilizing BCPAP on patients.

Design/Methods: We collected baseline data from 2018 of inborn neonates <32 weeks gestational age (GA) at birth admitted to the NICU. Exclusion criteria included significant congenital anomalies, death or transfer prior to discharge. After review of the data, our SMART AIM was to increase the rate of flexitrunk/BCPAP use in the DR from 0% to 50% within 6 months of guideline implementation (Figure 1A). We performed multiple PDSA cycles using high-fidelity simulation to determine the optimal equipment set up for the resuscitation of a preterm neonate that would incorporate BCPAP into the neonatal resuscitation. Initial PDSA cycles included sequential in situ simulations using a high-fidelity mannequin and resuscitation equipment to standardize the process of BCPAP commencement in the DR. The manikin simulated grunting and apnea; vital signs on monitors were used to reinforce effective versus ineffective CPAP. We initially used a flow-inflating bag from the radiant warmer and BCPAP on a transport pole to provide BCPAP or PPV. The process was recorded and the video was used to educate providers on the application of BCPAP and transition to PPV if necessary. On repetition of the simulation, we discovered there were limited oxygen/air wall supply outlets in some of the DR and suction apparatus was not functional with this set up. Therefore, through subsequent PDA cycles, we determined a T-piece resuscitator and BCPAP when connected to the radiant warmer allowed for both forms of necessary respiratory support to be available along with suction (Figure 2). Lastly, we began use of BCPAP with the flexitrunk interface on premature neonates.

Results: Preliminary results illustrate an increase in flexitrunk and BCPAP use in the DR, although a shift has not yet occurred due to small patient sample (Figure 1B).

Conclusion/Discussion: Use of high-fidelity simulation with QI methodology allowed for optimization of the use of BCPAP with the appropriate interface in the DR and allowed for increased safety of use on patients.