115 Clinical Decision Making in the Care of Preterm Infants at Risk of BPD Varies Significantly between Canadian Neonatologists

The Canadian Neonatal Network is studying the effects of collaborative quality improvement on NICU outcomes, including Bronchopulmonary Dysplasia (BPD).

To describe common decision-making criteria in respiratory care of newborns, variation between practitioners, and correlation of practice with scientific evidence.

We developed a 53-item questionnaire that examined clinical practice re: respiratory support, monitoring, weaning protocols, discharge criteria, use of diagnostic tests, fluids and medications, and personnel. Most questions were multiple choice. The questionnaire was distributed to all staff neonatologists in the study network in summer 2003.

28 neonatologists completed surveys. Management varied considerably among respondents. Forty-five percent would administer surfactant immediately after intubation to an infant <28 weeks gestation with RDS, while 48% would require x-ray confirmation. Thirty-four percent used high frequency ventilation routinely. The modal combination of monitoring was arterial line plus oxygen saturation monitor. Fifty percent used computerized respiratory waveforms to guide decision-making. Between rounds, decisions about respiratory care were made by Fellows (16), Residents (14), Respiratory Therapists (10) Nurse Practitioners (11), Clinical Assistants (9) Nurses (1) or Neonatologists (1). Fifty percent of clinicians reported using weaning protocols for RDS, usually administered by RTs. For preterm infants with RDS, the range of preferred maximum PaO₂ was 60–90 torr; preferred maximum PaCO₂, 45 torr to no limit; preferred minimum PaCO₂, 30–45 torr. The modal range of preferred oxygen saturation was 88–92% (range 85–95%). For infants developing BPD, modal maximum and minimum PaCO₂ was 60 and 40 torr, respectively. There was no consistent preferred range of oxygen saturation for BPD (range 85–98%). Many modes of ventilation were preferred; 13 of 28 respondents used volume guarantee during the weaning phase. FiO₂ was used as a criterion of extubation readiness in 23/28 cases, but clinical criteria were inconsistent. Forty-eight percent used methylxanthines as an aid to extubation. The maximum CPAP used ranged from 5 to >10 cm H₂O. Use of nasal flow oxygen was very inconsistent. Seven percent of clinicians never discharged infants on oxygen; 4% did so routinely. Seventeen clinicians reported using postnatal steroids for the treatment of BPD; 11 administered them systemically. The timing, dose and consent policies were not consistent. Vitamins A or E were not routinely used.

Canadian neonatologists' clinical decision making varies considerably even when scientific evidence is clear. Ongoing studies will address the influence of participation in benchmarking networks on the standardization of care and on clinical outcomes.