Evidence-based approach to change in clinical practice: introduction of expanded nasal continuous positive airway pressure use in an intensive care nursery.

OBJECTIVE Recent studies provide evidence that nasal intermittent positive pressure ventilation (NIPPV) may stabilize the airway of extremely low birth weight infants after endotracheal extubation. The objective of this project was to introduce the use of NIPPV into a busy level 3 intensive care nursery. METHODS This report describes the process of NIPPV introduction using a series of rapid-cycle improvement projects, as proposed by the Vermont Oxford Network. RESULTS In the first cycle, 7 (88%) of 8 infants were successfully extubated with NIPPV after meeting criteria for reintubation on nasal continuous positive airway pressure alone. Proper positioning of the prongs in the nasopharynx was found to be an important determinant of success. In a second cycle, shorter 2.5-cm nasopharyngeal prongs were more effective than standard 4-cm prongs in 12 recently extubated infants as assessed by objective measurements and subjective nursing reports. A third cycle confirmed the acceptance of this technique in our unit and demonstrated an associated decrease in markers of chronic lung disease in extremely low birth weight infants during the 22 months after its introduction. CONCLUSION This experience supports the role for the rapid-cycle change model in achieving effective evidence-based medical practices in a neonatal intensive care setting.