(45) Evaluating INSURE Use in Premature Infants as Part of a Quality Improvement Initiative

Blair Welch, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States; Alana Barbato, Riley Hospital for Children, Indiana University, Indianapolis, IN, United States

Background: Use of Intubate-Surfactant-Extubate (INSURE) is a one strategy to provide surfactant to premature infants with respiratory distress syndrome while avoiding prolonged exposure to mechanical ventilation.

Objectives: We evaluated the use of INSURE for infants born at < 32 weeks at our institution following creation of INSURE and intubation criteria for preterm infants as part of a quality improvement (QI) initiative.

Design/Methods: We implemented a QI initiative targeting decreased rates of intubation for premature infants admitted on non-invasive respiratory support, with INSURE as an initial intervention. We developed INSURE and intubation criteria (Figure 1), and patients were eligible to undergo INSURE if they met one of these criteria and were deemed appropriate by the care team. Baseline characteristics and details of respiratory support in the first week of life, including levels of respiratory support and maximum FiO2 requirements on non-invasive support, and rates of decompensation in the first week of life were obtained via the electronic medical record. Patients who underwent INSURE had additional analysis related to the procedure itself, including use of pre-medication and need for re-intubation either within 24 hours or within the first 7 days of life following INSURE procedure. We also analyzed the time at which patients required FiO2 of ≥0.3 to determine if lowering the FiO2 threshold would increase the number of eligible patients or decrease the time to surfactant administration.

Results: 47% of eligible patients had INSURE procedures since project initiation compared to 8% prior to the project (Figure 2). 54% of these patients never required subsequent placement on mechanical ventilation. 2 patients were re-intubated within 24 hours of INSURE and 3 patients who initially underwent INSURE were re-intubated within the first week of life for worsening respiratory status. Patients with successful INSURE attempts had a median gestational age of 30.7 weeks and median birth weight of 1433g. All but one patient received premedication with atropine and fentanyl prior to INSURE. If the FiO2 threshold was lowered to ≥ 0.3, INSURE could have occurred a median of 6.6 hours sooner and 6 additional patients would have qualified for treatment. There were no increases in the rates of decompensation in the first week of life following project initiation.

Conclusion: INSURE use increased since QI project initiation and decreasing the FiO2 threshold for INSURE criteria may allow for treatment with surfactant sooner.