Rates of bronchopulmonary dysplasia decreased after implementation of prevention bundle
Development and implementation of a novel bronchopulmonary dysplasia prevention system of care was associated with a sustained decrease in rates of bronchopulmonary dysplasia in infants, according to data published in JAMA Network Open.
“Bronchopulmonary dysplasia, or chronic lung disease, is a common, serious complication of prematurity. The incidence of [bronchopulmonary dysplasia] remains high and has been mostly unchanged during the last decade, ranging from 20% in California to 28% across the U.S. and 42% among infants less than 28 weeks’ gestation,” Maria Fe B. Villosis, MD, neonatal pediatrician in the department of pediatrics at Kaiser Permanente Panorama City, California, and colleagues wrote in JAMA Network Open. “Various interventions for the prevention of [bronchopulmonary dysplasia] have been studied, although their individual effects on bronchopulmonary dysplasia have either been modest or have influenced only short-term benefits. Significant variation in risk-adjusted rates of [bronchopulmonary dysplasia] holds out the hope that there are existing care practice interventions that, if identified and propagated, could significantly decrease [bronchopulmonary dysplasia] rates.”
Researchers conducted a quality improvement study of 484 infants (mean gestational age, 28.6 weeks; 52.1% female) with birth weights of 501 g to 1,500 g who were admitted to a level 3 neonatal ICU in the Kaiser Permanente Southern California health care system from 2009 to 2019. The researchers focused on three study periods: baseline (2009) when there was an increased rate of bronchopulmonary dysplasia; initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and full implementation of successive Plan-Do-Study-Act results (2015-2019).
A multidisciplinary team, including neonatologists, respiratory therapists and NICU nurses were involved in the quality improvement team. The quality improvement team developed key drivers for bronchopulmonary dysplasia prevention. The drivers included: a shared mental model focused on prevention of bronchopulmonary dysplasia; prevention to support postnatal lung growth and minimize inflammatory cascade and oxygen toxicity; consistent management to minimize variations in care; and management based on developmental stages of the lung, according to the study. In response to these key drivers, the team’s care practices evolved.
The primary outcome, bronchopulmonary dysplasia in infants with less than 33 weeks’ gestational age, decreased from 31% to 1.6% during the study period (P < .001).
In addition, the researchers reported that the standardized morbidity ratio for adjusted bronchopulmonary dysplasia in infants with less than 33 weeks’ gestational age was decreased from 1.2 in 2009 to 0.4 in 2019, according to the results.
There was also a decrease in rates of combined bronchopulmonary dysplasia severity grades 1, 2 and 3 (24.1% to 9.3%; P for trend < .008); grade 2 bronchopulmonary dysplasia rates decreased from 10.3% to 2.7% (P for trend = .02), according to the results.
Oxygen at home discharge decreased from 13.8% to 2.2% (P = .03),. One infant required tracheostomy tube placement in the 2015-2019 period, according to the results.
Researchers also observed a decrease in adjusted median postmenstrual age at home discharge from 38.2 weeks in 2009 to 36.8 weeks in 2017 to 2019, according to the results.
There was no changed in adjusted mortality during the study.
“We observed a substantial, sustained decrease in bronchopulmonary dysplasia rates in association with the development and implementation of a detailed bronchopulmonary dysplasia prevention bundle. Our success may be associated with a shared mental model of care that bronchopulmonary dysplasia is preventable, the details of the system of care, and the consistency of its execution,” the researchers wrote. “We believe the bundle of care described in this report is sufficiently detailed to enable researchers to assess whether these outcomes can be replicated at other centers.”