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Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle
Maria Fe B Villosis1, Karine Barseghyan1, Ma Teresa Ambat1
1Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California.
Insights
Implementing a Bronchopulmonary dysplasia (BPD) prevention bundle significantly reduced BPD rates in high-risk infants. This quality improvement initiative demonstrated a sustained decrease in BPD incidence and severity, improving infant outcomes.
Area of Science:
- Neonatal Medicine
- Pediatric Pulmonology
- Quality Improvement Science
Background:
- Bronchopulmonary dysplasia (BPD) remains a significant challenge in neonatal intensive care, with persistently high rates in the United States.
- Effective strategies for BPD prevention are crucial to improve outcomes for premature infants.
Purpose of the Study:
- To implement and evaluate a consistent Bronchopulmonary dysplasia (BPD) prevention bundle using a systematic approach.
- The goal was to achieve a significant reduction in BPD rates among high-risk neonates.
Main Methods:
- A quality improvement study involving 484 infants (501-1500g birth weight) in a level 3 NICU from 2009-2019.
- The study employed iterative Plan-Do-Study-Act cycles to develop and implement a BPD prevention system of care bundle.
- Outcomes included BPD rates (specifically BPD <33 weeks gestational age), BPD severity, and postmenstrual age at discharge.
Main Results:
- Bronchopulmonary dysplasia (BPD) rates for infants <33 weeks gestational age decreased significantly from 31.0% at baseline to 1.6% after full implementation (P<.001).
- The standardized morbidity ratio for adjusted BPD <33 decreased from 1.2 to 0.4.
- Rates of BPD severity grades 1-3 and grade 2 BPD also decreased significantly. Median postmenstrual age at discharge was reduced by 2 weeks.
Conclusions:
- A systematically developed and implemented BPD prevention system of care bundle can lead to sustained reductions in BPD rates.
- This approach demonstrates the effectiveness of quality improvement initiatives in improving neonatal outcomes for vulnerable infants.
Importance:
Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade.
Objective:
To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD.
Design, Setting, And Participants:
This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019).
Interventions:
A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable.
Main Outcomes And Measures:
The primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge. Balancing measures were adjusted mortality and adjusted mortality or specified morbidities.
Results:
The study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly.
Conclusions And Relevance:
A sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.
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