821 Think LISA, think CPAP

Abstract

<h3>Aims</h3> <h3>Background</h3> A 12-month audit of practice of a NHS Trust neonatal service, comprising a tertiary-level NICU and Local Neonatal Unit, against the NICE guideline for respiratory management in preterm neonates. In comparison to previous years, there was an increase in the use of mechanical ventilation in preterm babies, low rate of stabilisation on CPAP in the delivery room and low uptake of less invasive surfactant administration (LISA) technique. <h3>Objective</h3> Quality improvement project to understand the barriers to using primary CPAP in preterm neonate stabilisation and surfactant administration using the LISA technique. <h3>Methods</h3> A root cause analysis of the audit result was performed through qualitative data collection involving a pre-project survey and one-to-one interviews, conducted with staff involved in each LISA procedure. Thematic analysis identified main themes influencing clinical practice. Concurrently, LISA procedure teaching was incorporated into the educational programme. A post-project feedback survey assessed changes in staff perception following the education interventions. <h3>Results</h3> The pre-project survey of medical (73%) and nursing (27%) staff found willingness to consider primary CPAP for infants &gt;25 weeks’ gestation and birthweights of &gt;500g. Two-thirds of respondents had done &lt;5 LISA procedures. 20% had not performed any. Barriers identified to primary CPAP included individual competence, experience, equipment availability and clinical scenario factors. Barriers identified to LISA included uncertainty regarding accuracy of surfactant delivery and variable clinical expertise. 10 interviews with clinicians who performed LISA described their experience as positive, using adjectives such as ‘pretty good’, ‘straightforward’, ‘smooth’ and ‘positive’. Levels of supervision, confidence, teamwork and situational factors were recognised human factors. Preparation, equipment availability, technical aspects, complications and patient comfort were recognised procedural factors affecting experience of LISA. Most reported perceived ‘complications’ were in actual fact predictable side effects. 95% of participants reported improved confidence in performing LISA following the educational sessions. The post-project survey showed all respondents (83% medical; 17% nursing) had been involved in use of primary CPAP and LISA during the project timeframe. 88% of respondents took part in at least one educational session on LISA. 78% of session participants reported that educational sessions adequately prepared them for undertaking LISA, compared to 43% prior to the educational sessions. <h3>Conclusion</h3> Education, guideline implementation and familiarisation, workplace culture and equipment were the significant themes identified during the project. Perceived advantages of LISA included near-immediate clinical improvement. Reported disadvantages included risk of catheter misplacement, inadequate sedation and clinical instability during the procedure We demonstrated a positive change in confidence and experience with use of primary CPAP and LISA in our neonatal units, achieved by increasing awareness, proactive support for clinical LISA use, and a targeted, practical education programme. Our work has identified specific challenges with the LISA procedure such as uncertainty regarding catheter placement. This may be overcome by using video laryngoscopy. The local LISA guideline will be updated to address our project findings. The successful improvement of staff confidence and experience with the approach utilised in this project could be used to achieve changes in clinical practice in any neonatal or paediatric environment.