From InSurE to MIST: A Quality Improvement Initiative in a Level IV NICU

Objective: Mechanical ventilation is a key modifiable risk factor for bronchopulmonary dysplasia (BPD) in preterm infants with respiratory distress syndrome (RDS). Minimally invasive surfactant therapy (MIST) enables surfactant delivery to spontaneously breathing infants . MIST use has been associated with lower rates of adverse outcomes including death and BPD; however, uptake in U.S. NICUs has been variable. At our level IV NICU, Intubate-Surfactant-Extubate (InSurE) was the standard method for surfactant delivery in infants on non-invasive respiratory support. We aimed to increase MIST utilization and evaluate its impact on respiratory care practices and clinical outcomes. Study Design: A quality improvement (QI) initiative was launched with a SMART aim to increase MIST use from 3% to 80% within one year. Interventions included development of standardized guildelines, creation of procedural kits, multidisciplinary education, and identification of clinical champions. Iterative Plan-Do-Study-Act (PDSA) cycles were supported by real time audits and structured debriefings. Primary process measure was MIST utilization; secondary measures included procedural adherence, intubation within 7 days, and pharmacologic pre-medication use as a balancing measure. Results: MIST use increased from 3% to 97% of eligible infants within one year, with special cause variation and sustained centerline shift on p chart analysis. Procedural adherence was high, with only minor single step deviations on audit. The rate of intubation within 7 days of surfactant administration was unchanged pre and post MIST implementation (19% vs 18%). Pharamacologic pre-medication use decreased significantly from 17% to 1% (p=0.002). At the system level, the proportion of infants recieving surfactant via intubation decreased from 71% to 37%, reflecting a shift towards noninvasive respiratory management. Conclusion: A structured, multidisciplinary QI approach was associated with increased and sustained use of MIST and a shift toward noninvasive surfactant delivery. This initiative demonstrates the feasibility of implementing MIST in a high acuity level IV NICU.