From InSurE to MIST: A Quality Improvement Initiative in a Level IV NICU

Mechanical ventilation is a key modifiable risk factor for bronchopulmonary dysplasia (BPD) in preterm infants with respiratory distress syndrome (RDS). Minimally invasive surfactant therapy (MIST) enables surfactant delivery to spontaneously breathing infants. MIST use has been associated with lower rates of adverse outcomes, including death and BPD; however, uptake in the U.S. neonatal intensive care units (NICUs) has been variable. At our level IV NICU, Intubate, Surfactant, Extubate (InSurE) was the standard method for surfactant delivery in infants on non-invasive respiratory support. We aimed to increase MIST utilization and evaluate its impact on respiratory care practices and clinical outcomes.

A quality improvement (QI) initiative was launched with a specific, measurable, achievable, relevant, and time-bound (SMART) aim to increase MIST use from 3% to 80% within 1 year. Interventions included the development of standardized guidelines, creation of procedural kits, multidisciplinary education, and identification of clinical champions. Iterative Plan-Do-Study-Act (PDSA) cycles were supported by real-time audits and structured debriefings. Primary process measure was MIST utilization; secondary measures included procedural adherence, intubation within 7 days, and pharmacologic premedication use as a balancing measure.

MIST use increased from 3% to 97% of eligible infants within 1 year, with special cause variation and sustained centerline shift on p-chart analysis. Procedural adherence was high, with only minor single-step deviations on audit. The rate of intubation within 7 days of surfactant administration was unchanged pre- and post-MIST implementation (19% vs. 18%). Pharmacologic premedication use decreased significantly from 17% to 1% (p = 0.002). At the system level, the proportion of infants receiving surfactant via intubation decreased from 71% to 37%, reflecting a shift toward non-invasive respiratory management.

A structured, multidisciplinary QI approach was associated with increased and sustained use of MIST and a shift toward noninvasive surfactant delivery. This initiative demonstrates the feasibility of implementing MIST in a high acuity level IV NICU.

· Comparison of MIST versus InSurE.. · The effects of invasive ventilation.. · The use of sedation during MIST..