759 - Non-Invasive Positive Pressure Ventilation: A Quality Improvement Project Guided by Practice Preference Measurement

Publication Number: 1735.759

Sofia Gnecco, Beth Israel Deaconess Medical Center, Brookline, MA, United States; Emily Whitesel, Beth Israel Deaconess Medical Center, Boston, MA, United States; John Zupancic, Harvard Medical School, Boston, MA, United States; Munish Gupta, Beth Israel Deaconess Medical Center, Boston, MA, United States; Dewayne M. Pursley, Beth Israel Deaconess Medical Center, Boston, MA, United States; Helen Healy, Beth Israel Deaconess Medical Center, Brookline, MA, United States

Background: Extremely preterm infants are at increased risk of bronchopulmonary dysplasia, in part related to the need for prolonged mechanical ventilation. Early extubation to non-invasive support may reduce lung injury. Data suggest nasal intermittent positive pressure (NIPPV) may be associated with lower reintubation risk compared to nasal continuous positive airway pressure (CPAP). Understanding providers' practice preferences, an aspect of unit culture, may help facilitate successful implementation of practice changes favoring NIPPV use after extubation in the NICU.

Objective: The primary objective was to increase the percentage of infants born at < 28 weeks' gestational age (GA) requiring mechanical ventilation supported with NIPPV after first extubation. Secondary objectives included reducing reintubation rates within 7 days; and to assess unit culture change after guideline implementation.

Design/Methods: A practice guideline was developed, informed by prior measurement of staff practice preferences using the Neonatal Survey of Interdisciplinary Groups in Healthcare Tool (NSIGHT), as well as review of internal data. The guideline was implemented at a level III NICU in January 2023, and recommends extubation to NIPPV for infants < 28 weeks' GA and/or ≤ 1250g at birth. Data was analyzed between Jan 2022 - Sep 2025 using statistical process control charts to study NIPPV use after first extubation and number of extubations not requiring reintubation within 7 days in-between reintubation events. A previously validated and published vignette-based survey, the NSIGHT, was conducted in Aug 2025, and results were compared to those of previous 2017 and 2019 surveys.

Results: Over 3.5 years, 128 eligible infants were extubated. The rate of extubation to NIPPV increased from 28% to 83%, with a centerline shift in Q1 2024, corresponding to guideline implementation (Fig.1). Rate of reintubation within 7 days decreased from 33% in 2022 to 13% in the included portion of 2025. Rare events analysis of reintubation within 7 days demonstrated special cause variation in 2025, with an increasing number of extubations in-between reintubation events (Fig.2). Compared to 2017 and 2019, 2025 NSIGHT results showed a unit level net preference for NIPPV after extubation (p < 0.001) (Fig.3).

Conclusion(s): A practice guideline, informed by NSIGHT results and internal data, was implemented to promote extubation of infants born < 28 weeks' GA to NIPPV. Changes were achieved in clinical practice, reintubation within 7 days, and unit culture. Measuring unit culture may strengthen improvement work in neonatal respiratory care.

Figure 1. Extubation to NIPPV, Infants born < 28 Weeks' Gestational Age, P-Chart.
P-chart showing rates of infants born < 28 weeks' gestational age supported with NIPPV after first extubation.

Figure 2. Number of first extubation attempts with no need for reintubation within 7 days of extubation in-between reintubation events, 2022 - 2025, G-chart.
G-chart showing the number of first extubations that didn't require reintubation within 7 days in-between reintubation events also within 7 days of extubation. The center line was fixed as of December 2024.

Figure 3. NSIGHT Results, NICU staff practice preferences in 2017, 2019, and 2025.
Distribution of preferences among all NICU staff for three vignettes regarding the use of NIPPV versus CPAP in infants born < 28 weeks' gestational age. A mean greater than 3 indicates a net preference for CPAP, while a mean less than 3 indicates a net preference for NIPPV. A p-value < 0.05, as measured by the Wilcoxon Signed Rank Test, denotes a statistically significant preference for one of the two non-invasive support methods. Standard deviation (SD) indicates the level of agreement among staff, with lower SDs indicating higher agreement.