Implementation of an Extubation Readiness Guideline for Preterm Infants.

BACKGROUND: Intubated preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 32 6 / 7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. PURPOSE: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV NICU. METHODS: This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. RESULTS: Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt. IMPLICATIONS FOR PRACTICE AND RESEARCH: Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 32 6 / 7 weeks or less of gestation.

Improving On-time Administration of the Initial Hepatitis B Vaccine in the NICU.

Introduction: Despite the updated American Academy of Pediatrics recommendation for universal administration of the hepatitis B vaccine for newborns, delays in routine prophylaxis are common in the Neonatal Intensive Care Unit (NICU). Delayed immunization can increase perinatal acquisition risks and lead to subsequent delays in routine childhood immunization. This study aimed to increase the on-time administration of the birth dose of the hepatitis B vaccine from 46% to ≥70% at a level III and level IV NICU within the same health system. Methods: The stakeholder group developed project interventions using quality improvement methods, including implementing unit guidelines and a prompt in the progress note template. The outcome measure was the percent on-time administration of the initial hepatitis B vaccine for inborn NICU patients born to hepatitis B-negative mothers. The process measure was the percent on-time administration or a valid reason to delay immunization following the guidelines. Statistical process control P-charts graphically represented the measures to assess for change from January 2019 to May 2021. Results: In total, 2192 patients were included. The percent on-time administration improved from 48% to 57%. The percentage of on-time administration or valid reason to delay increased from 76% to 80%. Conclusions: Quality improvement methodology facilitated the identification of barriers to on-time hepatitis B prophylaxis in the NICU and the improvement of the timeliness of administration across 2 sites. Guidelines tailored to this population and changes to the progress note template successfully created and sustained change and may benefit other NICUs.