106 - Reducing Time to Surfactant Administration with the Lung Ultrasound Score: A Quality Improvement Study

Publication Number: 4104.106

Meghan Rowe, University of Washington School of Medicine, Seattle, WA, United States; Sarah Kolnik, University of Washington - Seattle Children's Hospital, Seattle, WA, United States; Nahee Park, University of Washington School of Medicine, Seattle, WA, United States; Tiffany Stanley, University of Washington School of Medicine, Seattle, WA, United States; Rishabh Jain, University of Washington, Seattle, WA, United States; Sandy Johng, Seattle Children's, Seattle, WA, United States

Background: Earlier surfactant administration in preterm infants is associated with decreased rates of chronic lung disease and air leak. The lung ultrasound score (LUS) has been demonstrated to have high sensitivity and specificity for predicting surfactant need and reduce time to surfactant administration.

Objective: Our specific aim is to increase the percentage of preterm neonates at an academic level IV NICU who receive surfactant within 3 hours of life (HOL) from 45% to 75% one year following LUS implementation.

Design/Methods: Neonatology fellows (n=7) and advanced practice providers (n=13) were trained to perform the LUS. The LUS was performed by 2 HOL for neonates >24 and < 34 weeks' gestational age (GA) on respiratory support who did not receive surfactant in the delivery room. If the LUS was >8, surfactant administration was considered. Weekly LUS quality assurance was performed. Interrater reliability was assessed with intraclass correlation (ICC). Clinical data was compared 6 months pre- and post-implementation. The proportion of eligible neonates who received the LUS was tracked as a process measure. Balancing measures included episodes of apnea/bradycardia requiring termination of the LUS scan and proportion of neonates who received surfactant.

Results: More birthing parents were steroid complete (p=0.01) and GA at birth and birth weights were lower (p=0.03) in the post-intervention group (Table 1). There was good interrater reliability between novice and expert LUS (ICC 0.70 [0.39, 0.87]). No episodes of apnea/bradycardia during the LUS required termination of the scan. The proportion who received surfactant did not differ between the two groups. Median time to first dose of surfactant was the same pre- and post- intervention. FiO2 at the time of surfactant was lower (p=0.02) and there were less episodes of pneumothorax in the post-intervention group, though this did not reach statistical significance (p=0.29) (Table 2). The proportion of eligible patients with a LUS increased to be above average, with insufficient data points for a center line shift (Figure 1A). The percentage of neonates who received surfactant within 3 HOL did not significantly change within 6 months of LUS implementation (Figure 1B).

Conclusion(s): Although incorporation of the LUS did not meet our specific aim of increasing the proportion of infants receiving surfactant by 3 HOL, it facilitated surfactant administration at lower FiO2 without increasing the proportion of neonates who receive surfactant, which may indicate that surfactant was administered prior to need for escalation in respiratory support.

Table 1: Maternal, Perinatal, and Neonatal Characteristics Pre- and Post-Intervention


Table 2: Neonatal Outcomes Pre- and Post-Intervention


Figure 1: Process and Outcome Measure P-Charts
Figure 1A: Process measure p-chart demonstrating the percentage of eligible neonates who received the LUS during the first 6 months of the QI project. Figure 1B: Outcome measure p-chart demonstrating the percentage of preterm neonates who received surfactant within the first 3 hours of life 6 months pre- and post-intervention.