Reducing NICU ventilator days by preventing fluid overload with the CAN-U-P-LOTS standardized bundle.

Background: Fluid overload in critically ill neonates and infants is associated with higher ventilation days, prolonged length of stay, and mortality.

Methods: This quality improvement study enrolled infants admitted to Children's of Alabama NICU (excluding those with tracheostomies, severe congenital kidney or heart disease, DNR status, or severe genetic conditions). We compared 7 months of pre-intervention data (211 neonates) with 7 months of post-implementation data (218 neonates). Bundle implementation for at least 5 days occurred for sepsis, spontaneous intestinal perforation, necrotizing enterocolitis, acute kidney injury, positive fluid balance >10%, hypotension, and major surgeries. The primary hypothesis was that the unit-wide ventilator-free days would increase after bundle implementation.

Results: We found special cause variation with an increase in the percentage of ventilator-free and oxygen-free days coinciding with bundle introduction. The ventilator-free days were higher in the post-era compared to the pre-era (5592/8335 (67%) vs. (3732/6619) (56%); p < 0.001). Oxygen-free days and NICU length of stay showed similar findings.

Conclusions: Implementation of a fluid overload prevention bundle was associated with increased ventilator-free days, oxygen-free days, and shortened NICU duration. Additional studies are needed to better understand these associations and externally validate our hypothesis in other populations.

Impact: Fluid overload leads to poor clinical outcomes, including the need for ventilatory support. Prolonged ventilation has a deleterious effect on the lungs due to barotrauma and leads to complications (i.e., pneumonia), longer length of stay, and increased costs. After consensus from a multi-disciplinary team, we implemented a strategy using the CAN-U-P-LOTS bundle designed to prevent fluid overload in critically ill infants. We showed an increase in the number of ventilator-free days, oxygen-free days, and shorter length of stay. Studies are needed to validate our single-center study.