The foundational steps used to initiate a bubble CPAP program are similar to other ‘Quality Improvement’ projects. These steps include:
The very first step in starting a bCPAP program is to identify team members. The team leader should aim to select and engage a multidisciplinary standing committee that will spearhead the change. The bCPAP team should consist of:
At least one lead physician
All levels are necessary: a nurse manager, charge and clinical nurses, however, one lead nurse should be identified
If they are part of NICU staff, it is better to engage feeding specialists at an early stage in the development of the bCPAP program. They will feed those who require bCPAP by mouth when developmentally ready
At least one lead neonatal nurse practitioner
At least one lead respiratory therapist
At least one lead member from the quality improvement team for proper design of the implementation program and optimal follow up and monitoring
Educating the implementing team about bubble CPAP (the why, how, and what) is the most important step for a successful bCPAP program. Proper education, orientation and familiarity of bCPAP leads to early success of the program and improved outcomes compared to prior entrenched methods. This visualization of positive change in the unit leads to change in the team’s attitude.
The team needs to properly become aware of the benefits of bCPAP as a unique non-invasive respiratory tool that improves outcomes. Neonatal ICUs that primarily use bCPAP in the management of preterm infants have been shown to have less chronic lung disease (CLD)1-4. The team needs to understand the conceptual foundation behind it and how it compares to other non-invasive and invasive respiratory interventions.
See educational modules
At a later phase, the team needs to discuss and finalize the implementation plan, training schedule, bubble CPAP equipment to be introduced into the unit (nasal interface, bubbler system, air/oxygen blenders and humidifiers, cannulaide, chin straps, etc.), a bedside checklist, a monitoring plan (items to be monitored), sharing monitoring results, educational intervention to correct implementation course, etc.
This step includes developing and finalizing a multi-phasic implementation plan
Bubble CPAP, although a simple bedside tool, is relatively labor intensive and requires gradual implementation and time for the team members to absorb and master the required steps. The bedside team needs time to go through the educational curve while learning how to assemble respiratory circuit, apply nasal interface, comply with bedside check list, troubleshoot, monitor quality, etc.
The implementation team needs to agree on a gradual transition plan where certain parts of the unit or a dedicated nursing team will start implement bCPAP (provided that they provide 24/7 coverage of the assigned beds). After success with a small cohort, the team should gradually adapt bCPAP usage to the remainder of the unit.
It is always better to start bCPAP on infants who are less sick in order to focus on learning and mastering technique, building skills and growing the confidence among staff members. Confidence in bubble CPAP needs to be built gradually to avoid setbacks of unexpected failure caused by lack of experience.
The following is a suggested schedule of a multiphasic gradual implementation plan:
| Phase | Gestational age or birth weight* | Duration |
|---|---|---|
| 1 | ≥ 32 weeks / ≥ 1500g | 4-6 months |
| 2 | ≥ 28 weeks / ≥ 1000g | 4-6 months |
| 3 | ≥ 26 weeks / ≥ 750g | 4-6 months |
| 4 | ≥ 24 weeks / ≥ 500g | 6 months |
| 5 | Any GA or BW | thereafter |
*Suggested birth weight and/or gestational age categories
The table above suggests to start with infants who weigh 1500 grams or more at birth, for 4-6 months. It is recommended that you should not start using bCPAP on any infant less than 1500g during the initial phase. Advance gradually to infants 1000-1499g after 4-6 months for a period of another 4-6 months. Continue progressing according the above guidelines until your team is comfortable using bCPAP on all infants, regardless of birth weight or gestational age, by 18-24 months from your bCPAP program initiation. Alternatively, gestational age categories may be used.
Regular evaluation and follow up meetings need to be in place. In the first 2-3 months, it should be every week to discuss obstacles and setbacks. Meeting frequency may space out gradually based on the team’s comfort level and success of implementation. However, at least once a month, a meeting should be conducted to assure quality and monitor outcomes.
Discuss and approve type of nasal interface, bubbler, chin strap, cannulaide, etc.
Team needs to discuss available options with hospital administration and agree on tools and equipment that the unit will commit to. Starter ups are encouraged to use nasal interfaces that have been associated with better outcomes in units that have shown consistently low chronic lung disease rates. The respiratory team needs to be comfortable with the respiratory equipment (humidifier, blender, circuits, bubbler, etc.) The team may use one of the commercially available bubblers or make their own as shown in our “Respiratory Circuit” under educational modules.
Provide training for the startup team on equipment to be used
All staff selected for initial implementation (physicians, nurses, respiratory therapists, etc.) must have hands-on training on the selected equipment to be used. Competency must be assured in all members of the pioneering team, as they will be the super-users who will teach and train the remainder of the staff.
Bubble CPAP policy and procedures need to be in a readily available file during the initiation phase until bCPAP is routinely used in your unit. The following policies are suggest:
How to properly and safely apply nasal prongs and secure respiratory circuit on infant’s head
Read MoreHow to set up respiratory circuit using in-house made bubbler and available equipment
Read MoreA check list of suggested items to be completed by the bedside nurse every shift
Read MoreImplementation should start as planned and team members should meet weekly to assess. Super-users should always be identified and available as main references for the implementation staff.
Implement a continuous and systematic education schedule for all staff members
All staff in the neonatal ICU need to be fully educated on the proper application, assembly, and use of bCPAP. Their competency in applying the nasal interface, setting up the bCPAP circuit, protecting the nasal septum, implementing the bedside checklist and troubleshooting should be verified and documented. The bCPAP team should modify this plan according to unit policies and culture. In certain units, all staff would be trained to perform all the steps. In others, RTs will take care of the circuit; nurses will handle the nasal interface and review bedside check list while quality personnel will assure standardization and monitoring.
New staff members need to have formal education, which includes foundational concepts, clinical scenarios, and periodic hands on sessions (i.e. every three months). Based on monitoring and quality assurance results as described below, existing staff may need to have refreshing courses or attend full educational program as designed by the bubble CPAP Committee. The quality assurance team should identify educational materials to be used as a refresher course. See different materials under “Educational Modules”: written chapters, recorded lectures by renowned bCPAP educators, along with demonstration videos.
All aspects of bCPAP, from the circuit to the patient, should be assessed periodically. The following list includes suggested items to be monitored at least once a week. Monitoring rounds should be unannounced and include all infants on bCPAP at the time.
| Item for evaluation | Response | |
|---|---|---|
| 1 | Prongs are the appropriate size for nares | Yes or No |
| 2 | Prongs are positioned correctly (i.e. bridge is not touching nasal septum) | Yes or No |
| 3 | Cannulaide is the correct size and properly adherent to skin | Yes or No |
| 4 | Velcro mustache is correct shape (i.e. corners rounded, thin) | Yes or No |
| 5 | Velcro mustache is properly positioned (i.e. not touching septum/nares) | Yes or No |
| 6 | Chin strap is used as indicated | Yes or No |
| 7 | Respiratory tubes are properly placed (i.e. not touching the eyes) | Yes or No |
| 8 | Water in bubbler is at the correct level | Yes or No |
| 9 | Water in bubbler is continuously bubbling | Yes or No |
| 10 | Flow meter is set at 5-7 liters/min | Yes or No |
| 11 | Oxygen saturation is at desired range (i.e. 90-93%) | Yes or No |
| 12 | Daily Bedside CPAP Checklist is complete for current shift? | Yes or No |
Data should be compiled and reviewed by the team on a monthly basis to promptly identify any deviation in implementation. Results could be displayed and shared as follow:
The graph above illustrates the overall compliance rate by month. The dotted line represents a compliance rate goal of at least 80%. The overall compliance rate per month is an average score of the evaluated items above.
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