Delayed Surfactant Administration in Preterm Infants: A Quality Improvement Project in the Clinical Process Improvement Program

Background: Preterm infants are at risk for respiratory distress syndrome due to immature lung development. The administration of surfactant reduces the risk of severe respiratory disease, and studies show that early surfactant administration, rather than delayed rescue administration, leads to a decrease in mortality and chronic lung disease, and a shorter duration on mechanical ventilation. From July 2023 thru September 2023 at a Level-III NICU, 56% of preterm infants born between 29 weeks gestational age and 37+6 weeks gestational age, not intubated in the delivery room, received surfactant administration more than 2 h after birth, which may lead to increased length of stay, more days on respiratory support, and may negatively impact long-term outcomes. Methods: A quality improvement project was conducted in conjunction with Mass General Brigham Clinical Process Improvement Program (CPIP). Process mapping identified main contributors to delayed surfactant; contributors were explored through a driver diagram. Diagnostic data was collected using retrospective chart review (n = 15). The most common causes for delayed surfactant administration were protocol not followed, waiting on chest x-ray/line placement, and borderline patient status. Baseline data (n = 27) showed the average time to surfactant administration was 3 h and 23 min. The driver diagram was expanded to include tertiary drivers and change ideas (Image 1). Two PDSA cycles were implemented: CXR text reminder, and noninvasive surfactant administration (SALSA). Results: The introduction of PDSA Cycle #1, a chest x-ray text reminder sent from the delivery room RT to the admitting team, included 5 eligible patients. PDSA Cycle #2, noninvasive surfactant administration, or SALSA, has included 9 patients to date. Following the first 2 SALSA patients, eligibility criteria was changed so that surfactant must be delivered within the first 8 h of life in order to be given via LMA. There appears to be a positive trend, at the time of abstract submission, due to the implementation of SALSA. The resulting data is displayed in an XmR chart (Image 2). Conclusions: Due to a decrease in eligible patient admissions/low census during the implementation of both PDSA cycles, there is insufficient data as of yet to determine if the interventions reduced time to surfactant administration. Data collection will continue as SALSA becomes a standard practice in this NICU. This project will inform future QI endeavors in this NICU.