Building the Driver Diagram: A Mixed-Methods Approach to Identify Causes of Unplanned Extubations in a Large Neonatal ICU.

BACKGROUND: The key driver diagram (KDD) is an important tool used by improvement teams to guide and frame their work. Methods to build a KDD when little relevant literature or reliable local data exist are poorly described. This article describes the process used in our neonatal ICU (NICU) to build a KDD to decrease unplanned extubations (UE) in chronically ventilated infants. METHODS: Twenty-seven factors hypothesized to be associated with UE in our NICU were identified. An expert panel of 33 staff members completed three rounds of a modified Delphi process administered through an online interface. After the third round, panel members provided suggestions for interventions to target all factors meeting criteria for consensus. These qualitative data were analyzed by inductive thematic analysis. A follow-up survey to all panel members was used to assess the feasibility of this process for future use. RESULTS: After three Delphi rounds, 14 factors met consensus and eight main interventions were identified through thematic analysis. These data were used to build a KDD for testing. All participants who completed the follow-up survey (20/20) stated willingness to participate in this process in the future and 18/20 (90%) stated they would be "more willing" or "much more willing" to support interventions developed using this process. CONCLUSION: A novel mixed-methods approach was used to generate a KDD combining a Delphi process with thematic analysis. This approach provides improvement teams a rigorous and reproducible method to understand local context, generate consensus KDDs, and improve local buy-in for improvement interventions.

Increasing Volume-Targeted Ventilation Use in the NICU.

BACKGROUND: In preterm infants who require mechanical ventilation (MV), volume-targeted ventilation (VTV) modes are associated with lower rates of bronchopulmonary dysplasia compared with pressure-limited ventilation. Bronchopulmonary dysplasia rates in our NICU were higher than desired, prompting quality improvement initiatives to improve MV by increasing the use of VTV. METHODS: We implemented and tested interventions over a 3-year period. Primary outcomes were the percentage of conventional MV hours when any-VTV mode was used and the percentage of conventional MV hours when an exclusively VTV mode was used. Exclusively VTV modes were modes in which all breaths were volume targeted. We evaluated outcomes during 3 project periods: baseline (May 2016-December 2016); epoch 1 (December 2016-October 2018), increasing the use of any-VTV mode; and epoch 2 (October 2018-November 2019), increasing the use of exclusively VTV modes. RESULTS: Use of any-VTV mode increased from 18 694 of 22 387 (83%) MV hours during baseline to 72 846 of 77 264 (94%) and 58 174 of 60 605 (96%) MV hours during epochs 1 and 2, respectively (P < .001). Use of exclusively VTV increased from 5967 of 22 387 (27%) during baseline to 47 364 of 77 264 (61%) and 46 091 of 60 605 (76%) of all conventional MV hours during epochs 1 and 2, respectively (P < .001). In statistical process control analyses, multiple interventions were associated with improvements in primary outcomes. Measured clinical outcomes were unchanged. CONCLUSIONS: Quality improvement interventions were associated with improved use of VTV but no change in measured clinical outcomes.

Specificity of back muscle response to submaximal fatiguing contractions.

A fatigue-related decrease in quality and accuracy of the proprioceptive feedback from muscle spindles in the back (e.g. stretch reflexes) may lead to a deterioration of spinal stability, thereby making the spine more vulnerable to external perturbations. Endurance time, tissue oxygenation, reflex latency and blood pressure response were studied in twenty subjects during a submaximal endurance test of the back extensors (20 % MVC) performed as either a position task (supporting a weight stack while maintaining trunk position) or a force task (exerting a force against a dynamometer). Mean endurance time was 8.91 (± 2.79) min for the force task and 10.86 (± 6.93) min for the position task. This result is in striking contrast to what has previously been reported from limb muscles, and suggests that back muscles are especially well suited for postural tasks. An increased reflex latency found after the position task indicates that the disadvantage of the prolonged endurance time is a deterioration of the afferent input from the muscle spindles that may potentially hamper the protection of the spine.

Dynamic training of the lumbar musculature to prevent recurrence of acute low back pain: a randomized controlled trial using a daily pain recall for 1 year.

PURPOSE: The purpose of this experiment was to quantify lumbar muscle endurance training for individuals with a recent episode of acute low back pain (LBP) (≥ moderate pain for ≥ 2 days) and to observe whether the training would reduce the rate and severity of recurrent LBP episodes. METHOD: Twenty-six participants who were pain-free at the time of the study were randomly divided into a high intensity back endurance (HIBE)-trained or a low intensity abdominal (LOAB)-trained (control) group. The HIBE-trained group performed preloaded maximum isokinetic exertions of the back extensors (five sets of 10 repetitions, 3 days a week for 4 weeks, totaling 12 sessions). The LOAB-trained group performed low intensity isometric contractions on their abdominals that had minimal effect on their back musculature. The two groups reported daily pain logs on a weekly basis on an interactive voice response telephone system for 1 year. RESULTS: The HIBE-trained group experienced more pain days (p = 0.038) in the minor and moderate categories and more episodes of acute LBP than the LOAB-trained group. However, there was a trend of less pain in the severe, intense and excruciating categories in the HIBE-trained group. CONCLUSIONS: The results of this experiment did not provide evidence that short-term intense training of the low back musculature provides protection against future episodes of LBP.