Improving Delivery Room Management for Very
Preterm Infants
abstract
BACKGROUND AND OBJECTIVES: Events in the delivery room significantly impact the outcomes of preterm infants. We developed
evidence-based guidelines to prevent heat loss, reduce exposure to
supplemental oxygen, and increase use of noninvasive respiratory
support to improve the care and outcomes of infants with birth
weight #1250 g at our institution.
METHODS: The guidelines were implemented through multidisciplinary
conferences, routine use of a checklist, appointment of a dedicated
resuscitation nurse, and frequent feedback to clinicians. This cohort
study compares a historical group (n = 80) to a prospective group
(n = 80, after guidelines were implemented). Primary outcome was
axillary temperature at admission to the intensive care nursery. Secondary outcomes measured adherence to the guidelines and changes
in clinically relevant patient outcomes.
RESULTS: Baseline characteristics of the groups were similar. After
introduction of the guidelines, average admission temperatures increased (36.4°C vs 36.7°C, P , .001) and the proportion of infants
admitted with moderate/severe hypothermia fell (14% vs 1%,
P = .003). Infants were exposed to less oxygen during the first 10
minutes (P , .001), with similar oxygen saturations. Although more
patients were tried on continuous positive airway pressure (40% vs
61%, P = .007), the intubation rate was not significantly different (64%
vs 54%, P = .20). Median durations of invasive ventilation and
hospitalization decreased after the quality initiative (5 vs 1 days
[P = .008] and 80 vs 60 days [P = .02], respectively).
CONCLUSIONS: We have demonstrated significantly improved quality of
delivery room care for very preterm infants after introduction of
evidence-based delivery room guidelines. Multidisciplinary involvement
and continuous education and reinforcement of the guidelines permitted
sustained change. Pediatrics 2013;132:e1018–e1025
AUTHORS: Sara B. DeMauro, MD, MSCE,a,b Emily Douglas,
MPH,a Kelley Karp, RN,b Barbara Schmidt, MD, MSc,b Jay
Patel, MD,a,b Amy Kronberger, MSN, RNC-NIC,b Russell
Scarboro, MA, RRT,b and Michael Posencheg, MDa,b
aDepartment
of Pediatrics, The Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania; and bThe Hospital of the
University of Pennsylvania, Philadelphia, Pennsylvania
KEY WORDS
preterm, temperature, thermal regulation, resuscitation,
outcomes of high-risk infants
ABBREVIATIONS
CPAP—continuous positive airway pressure
FiO2—fraction of inspired oxygen
QI—quality improvement
SpO2—oxygen saturation
Dr DeMauro contributed to writing and editing all drafts of the
manuscript, conception and design, and acquisition, analysis,
and interpretation of data; Ms Douglas contributed to writing
the first draft of the manuscript and to acquisition and analysis
of data; Ms Karp contributed to acquisition of data and critical
revision of the manuscript; Dr Schmidt contributed to study
conception and design, interpretation of the data, and critical
revision of the manuscript; Ms Kronberger contributed to study
conception and design and critical revision of the manuscript;
Mr Scarboro contributed to study conception and design and
critical revision of the manuscript; Dr Patel contributed to study
conception and design, acquisition of data, and critical revision
of the manuscript; Dr Posencheg contributed to drafting and
critical revision of the manuscript, conception and design, and
analysis and interpretation of data; and all authors approved
the final manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2013-0686
doi:10.1542/peds.2013-0686
Accepted for publication Jun 17, 2013
Address correspondence to Sara DeMauro, MD, MSCE, The
Children’s Hospital of Philadelphia, 2nd Floor Main Building,
Division of Neonatology, 34th Street and Civic Center Boulevard,
Philadelphia, PA 19104. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conflicts of interest to disclose.
e1018
DeMAURO et al
QUALITY REPORT
Events that occur in the first moments of
life can have considerable short-term
and long-term consequences, especially for very preterm infants. Specifically, 3 aspects of newborn care that
require prompt attention in the delivery
room are thermoregulation, respiratory
management, and oxygen delivery.
Hypothermia in the newborn is associated with much significant morbidity,
including hypoglycemia, respiratory
distress, hypoxia, and metabolic acidosis.1,2 The preterm infant is particularly
susceptible to hypothermia. In the EPICure cohort, admission temperature
,35°C was present in 40% of infants
,26 weeks’ gestation and was independently associated with mortality.2
Several interventions, including plastic
hats and wraps, warmer mattresses,
and warm delivery rooms, have been
shown to improve admission temperatures for preterm infants, but the majority of infants still become cold.3–12
Normal postnatal transition is associated with a slow rise in oxygen saturation from ∼60% to 90% over the first
5 to 10 minutes.13–16 Yet it is common
practice to provide supplemental oxygen, often without monitoring or specific saturation goals, during neonatal
resuscitation. Recent studies have
suggested possible harm associated
with the use of supplemental oxygen
during resuscitation of term infants.16–21
In preterm infants, active titration of
oxygen during resuscitation allows
more infants to achieve saturations
within a goal range, and initiation of
resuscitation with ,100% oxygen
results in similar heart rates during
resuscitation and lower rates of bronchopulmonary dysplasia.22–25
Several observational and randomized
clinical studies have compared immediate intubation and ventilation to use of
noninvasive respiratory support for preterm infants in the delivery room.26–31 All
of these studies reported trends toward decreased rates of death or
PEDIATRICS Volume 132, Number 4, October 2013
bronchopulmonary dysplasia in infants
initially managed with continuous positive airway pressure (CPAP). Although
many infants who initially received CPAP
eventually required intubation, there
was no evidence of harm associated
with early use of CPAP.
At the Hospital of the University of
Pennsylvania, we were inconsistently
using a warmermattressorplasticwrap
to prevent hypothermia, initiating resuscitation with 80% oxygen, and intubating all infants with birth weight ,750
g or gestational age #26 weeks. Given
the current literature, we designed an
intervention to prevent heat loss, reduce exposure to supplemental oxygen,
and increase the use of CPAP during
delivery room resuscitation of infants
with birth weights #1250 g. Our goal
was to use quality improvement (QI)
principals to standardize and improve
the quality and safety of delivery room
care for very preterm infants.
METHODS
Setting
There are ∼4200 births per year at
the Hospital of the University of
Pennsylvania. The 38-bed level III intensive care nursery is staffed by neonatologists, fellows, residents, nurse
practitioners, and physician assistants
from the Division of Neonatology at the
Children’s Hospital of Philadelphia,
which is located adjacent to our hospital, and respiratory therapists and
nurses based at the Hospital of the
University of Pennsylvania. After birth,
very preterm infants are immediately
brought to an adjoining resuscitation
room. Initial resuscitation is provided
with the NeoPuff device (Fisher & Paykel
Healthcare Inc, Irvine, CA), and then
patients are rapidly transitioned to
a Dräger Baby-Log ventilator (Dräger
Medical Inc, Telford, PA) for ongoing invasive or noninvasive respiratory support. Infants are transported to the
intensive care nursery after stable
respiratory status has been established
and umbilical lines have been placed.
Planning and Implementation of
the Intervention
A multidisciplinary team of neonatologists, nurses, and respiratory therapists
performed a thorough review of the literature and then crafted evidence-based
guidelines for the delivery room care of
infants with birth weight #1250 g. The
group presented their detailed recommendations to the Division of Neonatology at a formal conference in June
2010. The guidelines were circulated and
there was an opportunity for discussion
and modifications. The final guidelines
are displayed in Fig 1.
The guidelines were implemented between June and September 2010. Inservicing of the staff consisted of
small-group sessions with a slide show
and hands-on practice with the heat
loss prevention equipment. Several
approaches have ensured continued
enforcement of the guidelines. A
checklist is used to guide the team
through important steps before and
after delivery (Supplemental Information). Multidisciplinary simulation
training is used to reinforce the key
elements of the initiative. A dedicated
resuscitation nurse attends all daytime
deliveries and is responsible for ongoing training of clinical staff.
Several key process measures, including completion of the checklist, use
of thermoregulation equipment, and
details of respiratory management and
oxygen administration, are reviewed
after each resuscitation and then the
clinicians receive direct feedback. To
identify opportunities for process improvement, the QI and clinical teams
debrief within 24 hours of an admission
of a hypothermic infant. Process control
charts are used to continually monitor
admission temperatures and are discussed with the faculty each month. In
addition, data about delivery room
e1019
approved by the Institutional Review
Board at the University of Pennsylvania.
Analysis
Based on the literature, we assumed
an SD in admission temperature of
0.8°C.3 A sample size of 80 per group
was planned to allow 90% power to
detect a difference of one-half of an
SD (0.4°C).
FIGURE 1
Guidelines for delivery room resuscitation of infants with birth weights #1250 g, adopted in June 2010.
respiratory management and oxygen
use are reviewed during monthly QI
team meetings and then feedback is
given to the clinicians.
Evaluation of the Quality
Improvement Initiative
We performed a before/after cohort
study to examine the impact of our
clinical practice change. This cohort
study compared a historical control
group (“Epoch 1”) and a prospective
group (after implementation of the QI
initiative, “Epoch 2”). Eligible infants
were born at our institution with a birth
weight #1250 g. Infants were excluded
if the family and clinical team had plans
for “no aggressive measures” or “do not
resuscitate.” Retrospective data about
the historical control group were collected from patient registration logs
maintained in the nursery and from
electronic medical records. Prospective
data were collected from patient charts
throughout hospitalization.
The outcomes of this cohort study
were selected to measure both the
e1020
DeMAURO et al
effectiveness of the implementation of
the new guidelines and the impact of
these changes on patient outcomes. The
primary outcome was axillary temperature at the time of admission to the
intensive care nursery. Secondary outcome measures included the proportion of infants who were hypothermic at
admission, amount of supplemental
oxygen administered and corresponding oxygen saturations (SpO2), incidence of intubation without a trial of
CPAP, mode(s) of respiratory support
during resuscitation, and several clinically relevant patient outcomes. All
temperatures were classified based on
World Health Organization definitions:
hyperthermia .37.5°C, normal 36.5°C
to 37.5°C, cold stress/mild hypothermia 36.0°C to 36.4°C, moderate hypothermia 32.0°C to 35.9°C, and severe
hypothermia ,32.0°C.32 We defined
bacterial sepsis as a positive blood
culture and necrotizing enterocolitis
based on both clinical and radiologic
or surgical evidence. The study was
Baseline characteristics and outcomes
were compared between the groups
using t tests or Wilcoxon rank-sum tests
for continuous data, depending on the
distribution, and x 2 or Fisher’s exact
tests for dichotomous data, depending
on the sample size. Because continuous
staff education and feedback were
expected to lead to improved quality
over time, changes in admission temperature, incidence of intubation without an attempt to use noninvasive
respiratory support, and supplemental
oxygen (FiO2) exposure at 5 minutes of
life were further evaluated with statistical process control (XMR or P) charts.
To further analyze FiO2 exposure and
SpO2, we calculated the rate of change
of FiO2 or SpO2 for each patient over
time. We then used linear mixed-effects
models, which permit differential
follow-up times and account for withinpatient correlation. This approach
allowed us to include all observations
and the age in minutes at which they
occurred. The model included FiO2 or
SpO2 as the outcome variable, epoch
and time as fixed explanatory variables, and each individual patient’s intercept and slope as random effects,
and was used to produce figures
depicting average FiO2 and SpO2 over
the first 20 minutes of life.
Analyses were preformed with Stata IC/
11 (StataCorp LP, College Station, TX)
and statistical process control charts
were created with QI Charts (Process
Improvement Products, Austin, TX). We
considered 2-sided P values #0.05 to
be significant.
QUALITY REPORT
TABLE 2 Outcomes Related to the Quality Improvement Initiative
RESULTS
Eighty consecutively born infants were
enrolled in the historical cohort (January 2009 to June 2010, “Epoch 1”).
Eighty consecutively born infants were
enrolled in the prospective cohort
(October 2010 to January 2012, “Epoch
2”). Data collection occurred between
September 2010 and June 2012. Baseline characteristics of the 2 groups
were similar (Table 1).
At least 1 temperature was recorded
during resuscitation for 64 patients
(80%) during Epoch 1 and 80 patients
(100%) during Epoch 2. In Epoch 2,
infants were significantly warmer
during resuscitation (Table 2). Data for
the primary outcome, axillary temperature at the time of admission to the
intensive care nursery, was unavailable for 1 infant in Epoch 1 who did not
survive the initial resuscitation. There
was a significant increase in admission
temperature (36.4°C vs 36.7°C, P ,
.001) in Epoch 2. The proportion of
infants who were admitted with temperatures in the normothermic range
increased from 53% to 76% (P = .002)
and the proportion of infants who were
admitted with moderate or severe hypothermia decreased from 14% to 1%
(P = .003). In Epoch 1, 1 infant was hyperthermic at the time of admission. In
Epoch 2, 2 infants were admitted with
Epoch 1 (n = 80)
Epoch 2 (n = 80)
P value
36.3 (0.8)
36.4 (0.8)
36.6 (0.6)
36.6 (0.6)
36.7 (0.4)
36.8 (0.4)
0.01
,0.001
0.02
32 (40)
49 (61)
0.007
0.82
16 (53)
13 (43)
1 (3)
27 (55)
19 (39)
3 (6)
11 (37)
15 (50)
3 (10)
1 (3)
51 (64)
46 (58)
18 (37)
22 (45)
7 (14)
2 (4)
43 (54)
28 (35)
0.20
0.004
77 (25)
80 (22)
67 (27)
39 (23)
48 (24)
50 (28)
,0.001
,0.001
,0.001
60 (32)
68 (29)
81 (24)
55 (26)
70 (24)
85 (18)
0.47
0.61
0.32
Temperature
Temperature during resuscitationa
NICU admission temperature
Second temperature in NICU
Respiratory support
Any use of CPAP during resuscitation
Starting level of CPAP, cm H2O
5
6
7
Highest level of CPAP, cm H2O
5
6
7
8
Intubated in resuscitation roomb
Intubated without trial of CPAP
Supplemental oxygen
Fraction inspired oxygen, %c
0–1 min of life
2–5 min of life
6–10 min of life
Oxygen saturation, %c
0–2 min of life
2–5 min of life
6–10 min of life
0.94
All data are displayed as mean (SD) or n (%); temperatures are reported in °C. Outcomes include patients for whom the data
are available and were recorded in the infant resuscitation room unless otherwise indicated.
a If more than 1 temperature was obtained during the resuscitation, the first recorded temperature was used.
b This outcome excludes 1 patient in Epoch 2 who was intubated for surfactant only.
c The first available data point from each time interval was included.
temperatures of 37.6°C, just above the
upper limit of normal. Figure 2A is
a process control chart for admission
temperature, demonstrating both a
sustained increase in average admission temperature and decreased variability, reflected in the narrowing of
TABLE 1 Selected Baseline Characteristics and Delivery Room Interventions
Baseline characteristics
Gestational age, wk
Birth weight, g
Female
Cesarean section
1-min Apgar score #3
5-min Apgar score #3
Antenatal steroid therapy ($2 doses)
Delivery room interventions
Umbilical artery catheter
Umbilical vein catheter
Surfactant
Epinephrine
Chest compressions
Normal saline bolus
All data are displayed as mean (SD) or n (%).
PEDIATRICS Volume 132, Number 4, October 2013
Epoch 1 (n = 80)
Epoch 2 (n = 80)
P value
27.2 (2.5)
890 (224)
40 (50)
49 (61)
42 (53)
12 (15)
47 (59)
27.1 (2.6)
903 (245)
39 (49)
48 (60)
37 (46)
8 (10)
46 (58)
0.88
0.74
0.87
0.87
0.43
0.34
0.87
64 (80)
74 (93)
48 (60)
6 (8)
8 (10)
17 (21)
65 (81)
74 (93)
39 (49)
0 (0)
3 (4)
15 (19)
0.84
0.99
0.18
0.03
0.21
0.69
the control limits. The early shift of
the mean line, just before formal
guideline implementation, may represent increasing recognition of the importance of temperature regulation
even while the guidelines were still
under development.
The new guidelines did not lead to
a statistically significant decrease in
the number of delivery room intubations (Table 2). However, the percent of
patients who were intubated without
a trial of noninvasive support decreased over time (Fig 2B). The delayed
shift of the mean line in Fig 2B reflects
the ongoing work of the QI team after
formal implementation of the guidelines, providing frequent feedback to
the clinicians. Of those who were tried
on CPAP, there was not a significant
change in the failure rate in Epoch 2
(19% vs 31%, P = .23). We did not observe a change in the pressure at
e1021
exposed to less supplemental oxygen
during Epoch 2 (Fig 2C). Linear mixedeffects models were used to combine
all FiO2 and SpO2 data collected on individual patients over the first 20
minutes of life and develop the curves
depicted in Figs 3 A and B. These figures
describe average FiO2 (Fig 3A) and SpO2
over time (Fig 3B) during the 2 Epochs.
During Epoch 1, the FiO2 started at
∼80% and was weaned to ∼60% by 10
minutes. During Epoch 2, the FiO2
started at ∼40% and was titrated to
∼50% by 10 minutes. Despite these
differences, oxygen saturations were
nearly identical in the 2 groups.
We observed improvements in several
in-hospital outcomes after implementation of the new guidelines (Table 3).
Infants required fewer days of mechanical and noninvasive ventilation
and were less likely to receive postnatal steroids for treatment of chronic
lung disease. The median length of
hospital stay decreased from 80 days
to 60 days (P = .02). As balancing metrics, we did not observe increased
rates of admission hyperthermia or
pneumothorax or any other evidence of
harm during Epoch 2. Importantly,
there were no competing QI programs
aimed at these outcomes during our
observation period.
DISCUSSION
FIGURE 2
Statistical process control charts of A, axillary temperature at the time of admission to the intensive care
nursery (XMR chart); B, percent of infants who underwent endotracheal intubation without a trial of CPAP
(P chart); and C, percent supplemental oxygen administered at 5 minutes of life (XMR chart), per 5
consecutive patients and separated by Epoch. UCL, upper control limit; LCL, lower control limit.
which CPAP was started or the maximum pressure to which CPAP was
titrated. In Epoch 2, the average maximum amount of CPAP support for
infants who “failed” CPAP (n = 15) was
only 5.7 6 0.9 cm. A single infant in
Epoch 2 was treated with surfactant
and then placed back on CPAP. In post
hoc analyses, successful use of CPAP
e1022
DeMAURO et al
was not significantly related to gestational age, birth weight, or antenatal
steroid exposure in this population.
Monthly review of resuscitation data
revealed close compliance with the FiO2
titration guidelines. The process control chart for FiO2 recorded closest to
5 minutes, as a measure of compliance, demonstrates that patients were
We have demonstrated successful implementation of evidence-based guidelines for delivery room management of
very preterm infants at our institution.
We observed a significant increase in
the proportion of infants who were
normothermic when admitted to the
nursery, more infants were given a trial
of CPAP, and infants were exposed to
less supplemental oxygen during resuscitation. The quality initiative was
associated with significant improvements in several important patientcentered outcomes, including shorter
duration of ventilation and length of
QUALITY REPORT
initiative. Despite the decreased use of
supplemental oxygen during Epoch 2,
oxygen saturations were nearly identical. These results are consistent with the
published trials of supplemental oxygen
titration in preterm infants on which our
guidelines were based.24
FIGURE 3
A, Predicted fraction of inspired oxygen (FiO2). B, Oxygen saturations over the first 20 minutes of life, by
Epoch, with 95% confidence limits. Curves are based on linear mixed-effects models that incorporate
all available data. Epoch 1 is indicated by solid lines and Epoch 2 is indicated by dashed lines.
stay. Equally importantly, we have demonstrated that an approach to QI in the
neonatal ICU that uses a multifaceted or
“bundled” package of changes is feasible
and can result in substantial improvements in clinical care.
Previous research has demonstrated
that although individual interventions
such as a warmer mattress or occlusive
wrap will raise infant temperatures, they
do not provide sufficient protection to
ensure normothermia.3–12 Our unique
approach to prevention of heat loss
bundled the multiple strategies that
raise infant temperatures by small
increments. Ours is the first study to
demonstrate both an increase in average
PEDIATRICS Volume 132, Number 4, October 2013
admission temperatures to the normal
range and a substantial majority of
patients with admission temperatures in
the normal range. Importantly, our
infants are at high risk for preadmission
heat loss because it is local practice to
place umbilical lines before transfer to
the nursery. Nevertheless, our bundle
safely and effectively maintained infant temperatures in the normothermic
range throughout resuscitation and until
admission, without causing hyperthermia.
The significant difference in oxygen exposure between groups throughout the
first 10 minutes of life is furtherevidence
of successful implementation of the QI
Increasing evidence suggests that outcomes of infants who are managed with
delivery room CPAP are at least equal
to, and potentially better than, outcomes of those who are immediately
intubated.27,31,33,34 Despite the lack of
a statistically significant decrease in
delivery room intubations, our results
are similar to previous studies that
demonstrated associations between
increased use of delivery room CPAP
and decreased duration of mechanical
ventilation or oxygen dependence.27,31
One explanation for these results could
be that the QI intervention was associated with a culture shift toward decreased dependence on endotracheal
intubation and increased use of noninvasive support throughout the hospitalization. Alternately, reduced exposure
to hyperoxia and hypothermia in the
immediate postnatal period is associated with overall clinical improvements
in very preterm infants. Finally, our less
aggressive approach to respiratory
management was associated with lower
rates of cardiopulmonary resuscitation.
This is consistent with the SUPPORT Trial,
in which the rate of epinephrine use
was 4.1% in the intubation/surfactant
group and only 2.0% in the CPAP group,
and could have led to improved patient
outcomes.33
There are several potential reasons that
we have not yet observed a statistically
significant decrease in the number of
infants intubated in the delivery room,
despite the increased use of CPAP. It is
possible that our sample size was too
small to detect differences in this outcome. Alternately, as discussed earlier,
we first provide CPAP with a face mask
and NeoPuff device and then transition
e1023
TABLE 3 Respiratory and Other Clinical Outcomes
Epoch 1 (n = 80)
Epoch 2 (n = 80)
P value
Respiratory outcomes
Supplemental oxygen at 36 wk
Steroid treatment of lung disease
Pneumothorax
Duration of invasive ventilation, daysa
Duration of noninvasive ventilation, daysa
16 (24)
12 (17)
3 (4)
5 (1, 31)
26 (8, 39)
15 (22)
2 (3)
3 (4)
1 (0, 3)
18 (3, 30)
0.76
0.004
0.99
0.008
0.04
Other clinical outcomes
Deathb
Early bacterial sepsis
Late bacterial sepsis
Grade III/IV intraventricular hemorrhage
Patent ductus arteriosus
Retinopathy of prematurity requiring surgery
Necrotizing enterocolitis
Length of hospitalization, daysa
12 (15)
5 (6)
12 (18)
13 (17)
30 (42)
2 (3)
10 (14)
80 (59, 100)
11 (14)
2 (3)
17 (22)
7 (9)
28 (37)
3 (4)
8 (11)
60 (50, 80)
0.80
0.44
0.48
0.16
0.55
0.99
0.55
0.02
All data are displayed as n (%) or median (interquartile range). These results are for patients who survived long enough to
have the outcome assessed and for whom the outcome is known.
a These results are for patients who were discharged to home from the birth hospital and do not include those who died or
were transferred.
b Vital status is unknown for 1 infant who was lost to follow-up after transfer.
toappropriately sized nasal CPAP prongs
(3 sizes available, Medicomp Medical,
Princeton, MN) and the ventilator. Our QI
initiative did not include a change to
newer devices for respiratory support,
such as bubble CPAP, which has been
reported to reduce extubation failure in
this population.35,36 This choice of
equipment may be associated with our
incidence of CPAP failure. We do not
have data about the timing of CPAP administration or the duration of CPAP use
before infants were declared to have
“failed,” both of which will be important
factors in determining next steps in our
QI process. The guidelines suggest that
clinicians titrate CPAP “up to 8 cm as
needed to reduce work of breathing and
oxygen requirement”; however, the
maximum level of CPAP in the group who
“failed” was ,6 cm. In addition, only 1
infant underwent INtubate-SURfactantExtubate (“INSURE”) as recommended
for spontaneously breathing infants
with significant work of breathing. Previous studies have demonstrated that
policies encouraging use of CPAP are
increasingly successful over time, as
staff experience increases.27,31 As clinicians become more accustomed to the
use of CPAP in the resuscitation room,
we anticipate that they will be more
comfortable employing the INSURE
method of surfactant administration
and titrating to higher levels of support
before resorting to intubation.
In balance, changes in delivery room
management of very preterm infants did
not lead to increases in hyperthermia,
pneumothorax, or need for cardiopulmonary resuscitation in the delivery
room. We did not observe any adverse
effects associated with our evidencebased resuscitation guidelines.
QI initiative. The nurses and respiratory
therapists who are primarily responsible for implementation of several
aspects of the guidelines were involved
from the beginning. Therefore, the entire staff was, and remains, invested in
the success of the program. The presence of the checklist and delivery room
nurse during resuscitations, group
feedback after each delivery, and the
ongoing work of the QI team, reviewing
resuscitation data and process charts
with the clinical team at least monthly,
together allow for continuous reinforcement of the recommendations.
In next steps, we will develop a modified
version of the guidelines for low birth
weight infants between 1250 and 2000 g
and evaluate alternate strategies to
improve our use of delivery room CPAP.
Our study has several important limitations. With our sample size, we did not
have adequate power to draw conclusions about relationships between
the QI initiative and less common patient outcomes. In addition, as with all
observational studies, we can report
associations, but cannot conclude that
our practice change directly caused the
clinical outcomes that we report.
CONCLUSIONS
Several important factors are likely to
have contributed to the success of this
We have demonstrated significantly
improved quality of delivery room care
for very premature infants at our institution with the implementation of
evidence-based guidelines that address
3 aspects of delivery room management. The success of this QI intervention
was possible with multidisciplinary involvement and continuous reinforcement of the guidelines.
2. Costeloe K, Hennessy E, Gibson AT, Marlow
N, Wilkinson AR. The EPICure study: outcomes to discharge from hospital for
infants born at the threshold of viability.
Pediatrics. 2000;106(4):659–671
3. Trevisanuto D, Doglioni N, Cavallin F,
Parotto M, Micaglio M, Zanardo V. Heat
loss prevention in very preterm infants in
delivery rooms: a prospective, randomized, controlled trial of polyethylene
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