Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle

Abstract

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 MEASURESThe 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. RESULTSThe 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 RELEVANCEA sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.

Care Bundle to Improve Oxygen Maintenance and Events

“…Similarly, our study did not change BPD rates, possibly because the care bundle did not include many practices associated with reducing BPD. 32,33 We speculate that standardized monitoring of infant stability and early extubation and/ or weaning oxygen may have contributed to a reduction in invasive ventilation and supplemental oxygen days observed in this study. Our study's novel interventions were improved communication, staff ownership, 34 workflow integration, 35 and the use of readily available daily summaries from monitors with no sophisticated custom data acquisition or analysis.…”

Bronchopulmonary dysplasia in adults: Exploring pathogenesis and phenotype

“…Furthermore, the number of adult survivors of BPD requiring lung transplantation is on the rise. [115][116][117] These patients are at high risk of cardiopulmonary morbidity across the lifespan, but their disease course remains largely undescribed outside of childhood.…”

“…While gentler ventilation strategies, including the increasing use of noninvasive positive pressure ventilation, and mesenchymal stem cell therapy may reduce the incidence of BPD among neonates in the future, BPD continues to afflict 42% of all births at less than 28 weeks’ gestation in the United States. Furthermore, the number of adult survivors of BPD requiring lung transplantation is on the rise 115–117 . These patients are at high risk of cardiopulmonary morbidity across the lifespan, but their disease course remains largely undescribed outside of childhood.…”

Validation of an outpatient questionnaire for bronchopulmonary dysplasia control

“…1,2 One of the most common complications of preterm birth is bronchopulmonary dysplasia (BPD), a respiratory disease which affects the developing airways, alveoli, and pulmonary vasculature. 3,4 Despite advances in neonatal care, rates of BPD remain unchanged, 5 perhaps due to improved survival of infants born at earlier gestational ages. Preterm survivors with BPD frequently require respiratory support in the home setting, multiple daily medications, and frequent provider visits with a higher risk for rehospitalization.…”