O3226: Standardizing Continuous Positive Airway Pressure for Neonates in Borama, Somaliland Utilizing Quality Improvement Methodology

Purpose/Objectives: Respiratory distress syndrome, pneumonia, and apnea of prematurity are the most common causes of respiratory morbidity and mortality for patients admitted to the Borama Regional Hospital (BRH) neonatal intensive care unit (NICU). Continuous positive airway pressure (CPAP) therapy is the standard of care for neonatal respiratory distress and studies have shown improved survival when implemented in low-resource settings. Bubble CPAP (bCPAP) is a low-cost, non-invasive form of CPAP that requires less technical expertise to operate with a lower risk of patient complications. Baseline clinical audits at the BRH revealed multiple barriers to effective bCPAP delivery, including insufficient pressure supply, ineffective expiratory limb depth submersion, inability to blend oxygen, lack of neonatal-sized nasal prongs, and patient interface challenges.

Aim: Improve respiratory distress by increasing the rate of effective bCPAP delivery for all neonates less than 30 days of age admitted to BRH from 56% to 90% by December 31st, 2023.

Design/Methods: This is a single-center quality improvement (QI) initiative. Educational interventions were utilized to teach respiratory topics. Period 1 of project implementation included baseline data collection which occurred prospectively by auditing the current bCPAP system in the 2 months preceding all change ideas. Period 2 was the pre-implementation phase where the multidisciplinary team in BRH received a 2-week training course in QI methodology from international collaborators through a combination of lecture-based instruction and skills training. A clinical CPAP protocol to be used at BRH was created at this time. Period 3 was initiated when the BRH NICU bCPAP Protocol was released for use by all NICU staff. Study measures were collected through the REDCap clinical audit tool and are displayed using statistical process control charts.

Results: Eleven family medicine residents (4 PGY-1, 2 PGY-2, 5 PGY-3), 3 medical interns and 7 NICU nurses completed educational intervention ahead of bCPAP protocol release. Forty-five patients were initiated on the home-grown bubble bCPAP device during the study period. The bCPAP safety checklist audit form was completed at a rate of 47% (122/261) for the three 8-hour nursing shifts (shift A-C) while the patients remained on bCPAP. We achieved our study aim by demonstrating an increase in the rate of adherence to the 7-item bCPAP device set-up from a baseline of 56% to 93%. Additionally, the rate of infants weaning or discontinuing bCPAP for improved respiratory severity score increased from 0% to 18%. There was no increase in adverse event rates (rate of air leak, nasal columella breakdown and nasal irritation).

Conclusion/Discussion: This single-center quality improvement initiative provides a framework for implementing a standardized bCPAP clinical protocol with optimization of home-grown bCPAP design in a LMIC to increase the rate of effective bCPAP delivery and decrease respiratory distress.