An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

Background Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. Review of Evidence A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. Implementation An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. Evaluation This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. Sustainability Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. Conclusions Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS)

BackgroundTo create a theory-informed survey that quality improvement (QI) teams can use to understand stakeholder perceptions of an intervention.MethodWe created the survey then performed a cross-sectional survey of QI stakeholders of three QI projects. The projects sought to: (1) reduce unplanned extubations in a neonatal intensive care unit; (2) maintain normothermia during colorectal surgery and (3) reduce specimen processing errors for ambulatory gastroenterology procedures. We report frequencies of responses to survey items, results of exploratory factor analysis, and how QI team leaders used the results.ResultsOverall we received surveys from 319 out of 386 eligible stakeholders (83% response rate, range for the three QI projects 57%–86%). The QI teams found that the survey results confirmed existing concerns (eg, the intervention would not make work easier) and revealed unforeseen concerns such as lack of consensus about the overall purpose of the intervention and its importance. The results of our factor analysis indicate that one 7-item scale (Cronbach’s alpha 0.9) can efficiently measure important aspects of stakeholder perceptions, and that two additional Likert-type items could add valuable information for leaders. Two QI team leaders made changes to their project based on survey responses that indicated the intervention made stakeholders’ jobs harder, and that there was no consensus about the purpose of the intervention.ConclusionsThe Stakeholder Quality Improvement Perspectives Survey was feasible for QI teams to use, and identified stakeholder perspectives about QI interventions that leaders used to alter their QI interventions to potentially increase the likelihood of stakeholder acceptance of the intervention.

63 Characterizing Organizational Risk Factors and Clinical Impacts of Unplanned Extubations among Infants in the Neonatal Intensive Care Unit

Primary Subject area Neonatal-Perinatal Medicine Background Organizational factors in neonatal intensive care units (NICUs) can increase the risk of adverse events, such as unplanned extubations (UPEs). UPE is the premature and unanticipated removal of an endotracheal tube. UPE and subsequent reintubation may increase the risk for lung injury and bronchopulmonary dysplasia (BPD) among preterm infants. Objectives First, we aimed to assess the association between daily nursing overtime and UPEs in the NICU. Second, we aimed to evaluate the association between UPE, re-intubation after UPE, and BPD in the sub-group of infants born < 29 weeks’ gestational age (GA). Design/Methods We conducted a retrospective cohort study including infants admitted to a tertiary care NICU between 2016-2019. Daily nursing hours were obtained from local administrative databases. Patient data was collected from the local Canadian Neonatal Network database. Association between ratio of daily nursing overtime hours/total nursing hours (OTR) was compared between days with and without UPEs, using logistic regression analyses. Associations between UPE and BPD among infants born <29 weeks requiring mechanical ventilation was evaluated in a 1:1 propensity-score matched (PSM) cohort. Infants were matched based on GA ± 2 weeks, mechanical ventilation days at time of UPE ± 5 days and SNAPII>20. Results There were 108/1370 (7.8%) days with ≥ 1 UPE, for a total of 116 UPE events from 87 patients (23-42 weeks GA). Higher median OTR was observed on days with UPE compared to days without (3.3% vs. 2.5%, p=0.01). OTR was associated with higher adjusted odds of UPE (aOR 1.09, 95% CI 1.01-1.18), while other organizational variables were not (Table 1). Among ventilated infants <29 weeks’ GA (n=XX), UPE rate was 31% (59), BPD rate was 42% (81) and re-intubation rate after UPE was 59% (35). In the PSM cohort of infants <29 weeks, re-intubation after UPE, was associated with increased length of mechanical ventilation (aOR 16.45; CI 6.18, 26.72) as well as increased odds of BPD, when compared to infants not requiring re-intubation (aOR 4.97, 95% CI 1.54-18.27) (Table 2). Conclusion Higher nursing overtime was associated with increased UPEs in the NICU. Re-intubation was frequently required after a UPE. Among the infants born < 29 weeks’ GA, UPE requiring reintubation was associated with increased total length of mechanical ventilation and increased risk of BPD. Our findings highlight the role of workforce management in improving outcomes in the NICU, through reducing the incidence of UPEs.