A quality improvement initiative in reducing nasal trauma during the application of nasal bubble continuous positive airway pressure in a tertiary care neonatal unit

Abstract

Background: Trauma following nasal bubble continuous positive airway pressure (bCPAP) is more commonly observed in areas where there are inadequate nursing staffs. It may progress to be a source of sepsis, prolonged hospitalization, and permanent facial disfigurement. Aim: This study aims to conduct a quality improvement (QI) initiative to decrease the proportion of neonates developing nasal trauma following bCPAP from baseline of 79% to 30% over a period of 16 weeks in Level III neonatal intensive care unit of a tertiary hospital of South India. Materials and Methods: The study was conducted as a single-center QI initiative from October 2018 to February 2019. A QI team was formulated, problem/outcome indicator decided and problem analysis was done using fishbone analysis and Pareto principle. Change ideas were discussed and plan, do, study, and act (PDSA) cycles were formulated. It took four PDSA cycles to reach the aim. The first cycle aimed to train nurses, second to reinforce the same in treating doctors, third was to start using Duoderm (gel plaster) over nasal septum, and the fourth was to intermittently shift the baby to high-flow nasal cannula and introduction of written policy to maintain the changes introduced. Results: Incidence of nasal trauma reduced from baseline of 79% to 26% over a period of 16 weeks. Incidence of Grade III trauma reduced from 35% to 0%. Conclusion: A simple method of training the junior residents and nursing staff and use of barrier gel plaster and maintaining policy on the application of nasal CPAP (NCPAP) can go a long way in reducing NCPAP trauma substantially and hence helping reduce hospital stay, morbidity, and probably also sepsis-related mortality.