768 - Tennessee’s Tiniest Babies: Reducing Chronic Lung Disease in Very Preterm Infants

Publication Number: 1744.768

Malinda N. Harris, East Tennessee Children's Hosp, Knoxville, TN, United States; Vineet Lamba, Sutter Children's Center, Rocklin, CA, United States; Alicia Mastronardi, Tennessee Initiative for Perinatal Quality Care, Knoxville, TN, United States; brenda F. Barker, TIPQC, Brentwood, TN, United States; Patricia A. Scott, Tennessee Initiative for Perinatal Quality Care, Mt. Juliet, TN, United States; Scott Guthrie, Children's Hospital at Erlanger, Chattanooga, TN, United States

Background: The Tennessee Initiative for Perinatal Quality Care (TIPQC) launched Tennessee's Tiniest Babies (TTB) to reduce infant mortality through four care bundles targeting severe intraventricular hemorrhage (sIVH), chronic lung disease (CLD), necrotizing enterocolitis (NEC), and hospital- acquired infections (HAI) in Level 3 and 4 neonatal intensive care units (NICUs). Per Vermont Oxford Network data, CLD affects 31.3% of infants (≤29.6 weeks gestational age [GA]), with a pre-project baseline of 35.8% (2019-2021) in participating Tennessee NICUs.

Objective: Reduce CLD incidence by 25% (from 2019-2021 baseline) in ≤29.6-week GA infants by June 2024 in Tennessee's Level 3 and 4 NICUs, with a secondary aim to reduce mortality by 25% by TTB project completion.

Design/Methods: A toolkit of Potentially Better Practices (PBPs) was developed (Figure 1), including antenatal steroids, magnesium sulfate, immediate CPAP (≥5 cm H2O) in the delivery room, caffeine within 24 hours of birth, room air trials, multidisciplinary staff education, unit-specific guidelines for early surfactant and extubation, and inclusion of a patient family partner (PFP). Following IRB approval, Phase 1 (2024-2025) involved monthly huddles and quarterly learning sessions across participating NICUs. Data were collected via SimpleQI, tracking process measures (CPAP use, caffeine administration, guideline compliance) and balancing measures (pneumothorax, sIVH, dexamethasone use). Phase 2 (2025-present) focused on sustainment while integrating additional TTB bundles.

Results: Ten of 12 eligible NICUs implemented PBPs, impacting 672 ≤29.6-week GA infants. Twelve huddles were held during Phase 1. Table 1 shows an increase in all PBPs. Compliance in early surfactant guideline development was 100% and extubation guideline development increased from 55% to 73%. Fifty percent of teams added a PFP. Balancing measure of pneumothorax was within the expected range. Post-intervention, CLD was 41.2% (Fig. 2a). Grade 3 CLD declined from baseline without statistically significant variation (Fig. 2b). There were no CLD deaths during the project compared with a baseline of 2.6%.

Conclusion(s): Ten Tennessee NICUs successfully adopted the CLD bundle through TIPQC's statewide collaboration. Reduced Grade 3 CLD and zero CLD-related mortality suggest progress despite missing the primary goal. TTB continues to advance neonatal outcomes, with CLD in sustainment, NEC underway, and HAI in development.

Figure 1. Key Driver Diagram
Key Driver Diagram used within the Tennessee's Tiniest Babies CLD bundle toolkit.

Figures 2a and b. Chronic lung disease and grade 3 chronic lung disease.
These figures represent the monthly rate of overall CLD and grade 3 CLD throughout the project, showing a trend toward less variability and reduction.

Table 1. Baseline comparisons on process measures
This table shows a comparison between process measures in the first 3 months of the project and the last 3 months of the project. There was a general improvement across the board in the adoption of identified PBPs by all sites. Additionally there was no significant change in the rates of our balance measures, pneumothorax and severe IVH.