502 - Application of 2022 NICHD BPD risk estimator for timely identification of neonates at highest risk for bronchopulmonary dysplasia in the Neonatal ICU: A multicenter Quality Improvement Initiative

Publication Number: 502.3780

Ana H. Martinez, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States; Joana Machry, Johns Hopkins All Children's Hospital, SAINT PETERSBURG, FL, United States; Maureen M.. Gilmore, MD, Johns Hopkins University School of Medicine, Towson, MD, United States; Michelle Gontasz, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Aaron M. Germain, Johns Hopkins All Children's Hospital, Tampa, FL, United States; Oscar G. Winners-Mendizabal, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States; Samar Atteih, Johns Hopkins University, Baltimore, MD, United States; Kartikeya Makker, Johns Hopkins Children's Center, Baltimore, MD, United States; Suneetha Desiraju, Johns Hopkins University School of Medicine, Baltimore, MD, United States

Background: Extremely premature neonates exposed to prolonged mechanical ventilation are at the highest risk for bronchopulmonary dysplasia (BPD). Timely identification of patients at the highest risk and targeted prescription of systemic corticosteroids (SC) based on risk assessment has potential benefits for disease rate and/or severity reduction, minimizing exposure to side effects. Risk assessment is available with an online tool developed by the Neonatal Research Network, the BPD outcome estimator 2022 (BPDe2022).

Objective: Global

Aim: Reduce the incidence and/or severity of BPD in neonates born at gestational age (GA) < 28 weeks at three Johns Hopkins Neonatal Intensive Care Units by April 2025.
Primary aims: Improve the timely identification, at 14 and 28 DOL, of >50% of eligible neonates, < 28 weeks or < 1000 g, at greatest risk of grade 2/3 BPD and death using the BPDe2022, by April 2025.
Secondary

Aim: Increase the timely and appropriate initiation of SC in compliance with the standardized clinical pathway (CPG) adopted by all clinical sites (April 2024) by 20% by April 2025.

Design/Methods: Quality Improvement (QI) methodology was applied. Plan-Do-Study-Act Cycles (PDSA): #1-EMR alert for BPD risk estimation (completed). #2-Standardization of risk assessment documentation on progress notes using a “Smart Phrase” (completed). #3-Provider education on performing BPD risk assessments accurately (in process). #4-Education on CPG for SC target prescription for BPDe2022 risk estimation >60%.
Outcome measures: Identification of neonates at highest risk of BPD/Death by 28 DOL; actual rate of Survival/BPD; % SC prescription according to CPG; time to extubation after SC. Process measures: documentation of BPD risk at 14 and 28 DOL; functionality of EMR alert; accuracy of documented BPD risk estimation. Balancing measures: number of SC courses prescribed; rate of adverse effects related to SC.

Results: Since launching the project, 70 ELBW neonates met criteria for BPDe2022. Table 1 shows Demographic and Outcomes data comparing baseline and QI patients. Overall rates of all grades BPD, except Grade 3 decreased in QI patients. Increasing number of neonates had risk assessment documented on EMR (Figure 1) and were prescribed SC if risk for grade 2/3 and death >60% (Figure 2).

Conclusion(s): After completing two PDSA cycles >50% of eligible neonates had a BPD risk assessment documented on EMR and >70% received SC in compliance with the CPG. The impact of the initiative resulted in reduction of rates of BPD grade 1,2 and death without significant increase in side effects.

Table 1
Demographics and Outcomes data for Baseline and QI population after 2 PDSA Cycles.

Figure 1
Control chart showing BPD risk assessments performed at 14 or 28 days of life for neonates at highest risk of BPD.

Figure 2
Control chart showing SC prescribed appropriately according to current standardized clinical pathway (>60% of combined risk of grade 2/3 BPD and death)