#014 - The NICU Superpower-transforming NICU care with POCUS

In this episode, Dr. Meghan Rowe discusses her journey as a POCUS fellow at the University of Washington and Seattle Children's Hospital. She shares her experiences with a quality improvement project aimed at improving surfactant administration for neonates with respiratory distress syndrome. The conversation covers the importance of mentorship, the challenges of implementing new practices, and the perspectives of nursing staff and parents. Dr. Rowe emphasizes the significance of training and collaboration in enhancing neonatal care through point-of-care ultrasound.

Transcript

Srirupa (00:00.962) Hey everyone, welcome back to another fantastic episode of Rupa's Fellows Friday. I am very excited to welcome our new guest today, Dr. Meghan Rowe from University of Washington and Seattle Children's Hospital. Meghan is currently a second-year going into third-year fellow, and she is quite frankly amazing. And I got to tell you the story of how I met Meghan.

I met Meghan when she was an instructor for a POCUS (Point-of-Care Ultrasound) workshop at PAS (Pediatric Academic Societies). And I was quite frankly so impressed with her confidence and with how beautifully she taught in that POCUS workshop. I am very excited to highlight and discuss a lot more about her POCUS interest in our episode today. Meghan, welcome to the episode.

Meghan Rowe (00:52.247) Thank you so much for having me.

Srirupa (00:53.932) I am so happy that you're here today. I think you're the first POCUS fellow coming onto the episode. I would first want to know how you got interested in POCUS and how that's flourished during your fellowship.

Meghan Rowe (01:10.935) Absolutely. I count myself as very fortunate to be in a fellowship program that has two amazing champions for point-of-care ultrasound, namely Dr. Sandy Jung and Dr. Sarah Kolnick. They've really taken on teaching fellows, but not only fellows — they also do a lot of teaching for our advanced practice providers and attendings. They are really advocates for incorporating POCUS into our clinical practice as an extension of the physical exam. We do quarterly didactics and hands-on sessions, and I just found that this is a great skill with a lot of utility in our unit.

So I took the opportunities I could to learn more and have gone to some conferences with POCUS focuses to really improve my skills. The benefits of POCUS are that it's non-invasive, you can usually do a pretty quick exam, and it often doesn't require as much movement of the baby — especially for the lung ultrasound. So it's something that doesn't interrupt the care of the baby but gives you a lot of really helpful data.

Srirupa (02:38.818) I can echo that, because my clinical care has gotten a lot more insight with POCUS implementation. It's such a helpful tool, and I'm so glad that we have national institutions like the National Neonatal POCUS Collaborative that are so supportive of these endeavors across institutions. That's wonderful, Meghan. So how about you tell us a little bit about your fellowship project? I would love to hear what got you interested in that particular project, how you found your mentor, and how the project came about.

Meghan Rowe (03:13.813) Absolutely. I'll start with just a little background. My project is a quality improvement project for improving time to surfactant administration for our neonates with clinical signs of RDS (Respiratory Distress Syndrome).

It really started with the mentors I have. The project was inspired when we were looking at our unit's data, which showed that only about 45% of the neonates born at the University of Washington with signs of RDS were receiving surfactant within the first four hours of life. There was a meta-analysis done a number of years ago that looked at six randomized control trials comparing earlier surfactant — within the first few hours of life — to delayed surfactant administration. That meta-analysis showed that earlier surfactant was associated with a reduction in neonatal mortality, chronic lung disease, and decreased risks of pneumothorax, PIE (Pulmonary Interstitial Emphysema), and overall air leak syndromes.

So my mentors, Dr. Sandy Jung and Dr. Sarah Kolnick, and I were thinking about how we could improve our time to surfactant administration. We felt that point-of-care ultrasound could potentially be a good way to identify an additional clinical sign that babies might benefit from surfactant in that earlier timeframe.

When we looked at the neonates in the unit who were receiving surfactant beyond that four-hour window, many were already on CPAP (Continuous Positive Airway Pressure) of six, had tachypnea, and increased work of breathing, but they didn't yet meet the criteria based on FiO2 (Fraction of Inspired Oxygen). Our unit uses FiO2 greater than 30% for surfactant administration. We felt that POCUS could serve as an additional clinical marker — identifying babies who might eventually meet that FiO2 criteria and giving us an earlier indication that they could benefit.

Meghan Rowe (05:30.677) I should also share the research background on POCUS and its use for surfactant decisions. Point-of-care ultrasound has been shown to differentiate between other early pulmonary diseases of the newborn, namely TTN (Transient Tachypnea of the Newborn). One concern is whether we might give surfactant to a TTN baby instead of one who actually has RDS. Consistently, the point-of-care ultrasound scores are different at hours one, two, three, and four, with higher scores for RDS compared to TTN.

We also looked at the data on POCUS use for surfactant administration. There's a systematic review and meta-analysis by Capasso et al. (2023) that demonstrated POCUS scoring had high sensitivity and specificity for predicting the need for surfactant based on traditional FiO2 criteria. Then the question becomes: does using ultrasound actually lead to sooner surfactant administration? That's also been studied. The Ultra-Surf randomized control trial compared using a lung ultrasound score greater than eight to determine surfactant administration versus a control arm using FiO2. In that trial, 100% of babies in the ultrasound arm received surfactant by three hours of life, compared to only 6% in the FiO2 arm.

There's also a group in Paris that performed a quality improvement project where they introduced lung ultrasound score as an additional criterion for surfactant administration. When using FiO2 greater than 30% or a lung ultrasound score greater than eight — whichever occurred first — the percentage of babies receiving earlier surfactant increased from 70 to 90% post-intervention.

Meghan Rowe (07:46.313) They also looked at duration of invasive ventilation days post-intervention and found a reduction. So there is a lot of robust evidence for using POCUS to decide whether a baby would benefit from surfactant and for reducing the time to surfactant administration. Frankly, I was surprised by how much robust data exists, because point-of-care ultrasound has just been a little slower to pick up in the United States. But there really has been a lot of work in other countries to show that this is a helpful tool.

So we decided to bring this into our unit. We started our first PDSA (Plan-Do-Study-Act) cycle in August of 2024, so we're getting close to a year now. Our goal is to perform a lung ultrasound exam on all neonates born under 34 weeks gestational age who are on any sort of respiratory support by one hour of life — which in our unit is standardly CPAP. The goal is to perform a lung ultrasound score by two hours of life. A lung ultrasound score greater than eight has been set as an additional clinical piece of information that can guide surfactant administration. We still have our classic FiO2 greater than 30%, but now we're saying: if you have clinical signs of RDS, an X-ray with typical findings, and either the FiO2 or the lung ultrasound score greater than eight, those would be indications to give surfactant.

I have to give a big shout out to all the advanced practice providers, fellows, nurses, and respiratory therapists in our unit, because this was definitely a big change to our practice. The QI project wouldn't be possible without everyone's willingness to learn the new skill, change our practice, and perform this in the first few hours of life while everyone is focused on getting the baby settled in.

We finished our first six-month PDSA cycle and are currently in our second. In that first cycle, the number of babies on whom we were performing lung ultrasound — those who met the criteria — increased from about 30% when we started to 75%. Scoring reliability, which is really important, has also significantly improved. A few of us who have become very familiar with lung ultrasound and scoring review every single exam and the scores given, and we provide feedback to make sure everyone feels comfortable. One important next step we've identified is creating an educational module and scoring guide to help those who spend less time in the unit get refreshers on how to do this.

Srirupa (11:09.622) That's amazing. How did you manage the logistics of knowing who would do the lung ultrasound? For example, if you are not on service and there's a baby that was born, or you're out of town — did you identify champions available for doing these lung ultrasounds?

Meghan Rowe (11:32.983) Great question. To really make this QI project successful, we needed people in the unit trained on how to do the lung ultrasounds. So we have trained every fellow and all of the advanced practice providers who work in the unit on how to perform it. We've had a couple of teaching sessions followed by hands-on practice, and we've done multiple sessions throughout the QI project to make sure people feel comfortable and have had refreshers. We do QA (Quality Assurance) reviews to give real-time feedback on scoring.

At any given time, we have at least two advanced practice providers or fellows in the unit. There are definitely some people who have really taken to point-of-care ultrasound and have become the champions in the unit, but many others are also absolutely willing to learn and have jumped at the opportunity. It's impossible for me to be in the unit all the time since we cover two different units, so it's really only been possible because we've had so much enthusiasm from everyone in our group.

Srirupa (12:58.958) That's awesome. What were some of the challenges you had while implementing the project?

Meghan Rowe (13:04.737) Great question. I think one of the biggest challenges has been that while we've had a lot of focus on training fellows and advanced practice providers — and most of us now feel very comfortable performing and scoring the exam — we realized we needed to spend more time introducing and training the faculty and attendings.

POCUS has been slower to come to our units, and we needed to make sure attendings also felt comfortable with this exam and incorporating it into clinical practice. There were times when exams indicated surfactant administration but it wasn't happening, and it was often because the attending just didn't feel comfortable following something other than our traditional FiO2 criteria. I've done a couple of teaching sessions for faculty via lectures, and we've been doing unit-wide POCUS sessions for our division. As I mentioned, the educational module we're developing could be very helpful — giving all the attendings who rotate in that unit a training and scoring guide they can refresh themselves on. Our division is very large and faculty rotate at different sites, so even though fellows and APPs (Advanced Practice Providers) who work in the unit are there frequently and are now becoming very comfortable, we need to make sure the attendings are, too.

Srirupa (14:57.578) Absolutely. And with quality improvement projects, we always think about the frontline providers and the attendings. Can you share how the nurses responded? Because they're so protective — and I love that they are — of our patients. Ultrasound can sometimes be distressing for babies, so how was that perceived by nursing? And in the same context, how did parents perceive it, since parents who come by might be wondering what's going on with this ultrasound?

Meghan Rowe (15:39.607) I agree that it was really important, and this truly wouldn't be possible without the cooperation of our amazing nurses. I will say people accepted this pretty quickly. Part of the reason is that we try to work with our nurses to find a time that works best for them.

We're trying to do the lung ultrasound within the first two hours, and when we have a baby — particularly the earlier gestational age ones — we're trying to get them settled in during the golden hour, so we really have to work quickly as a team to find the best moment after we've given vitamin K and placed our lines. The nice thing about the lung ultrasound exam is that we're looking at regions that are easier to access — both the right and left upper anterior, lower anterior, and lateral sides — without having to turn the baby over. That helps because it's an exam we can do without really disrupting the positioning of the baby. We also keep gel packets in the warmer so the gel is warm, which makes it less disruptive for the babies. With someone helping save the images, you can get the exam done within a few minutes.

I think all those things have made it more accepted by our nurses. I don't want to minimize that it is an additional thing we're doing — sometimes EKG leads get a bit of gel on them — but we've been trying to minimize the disruption as much as we can. Our nurses and everyone in the unit are also starting to see how helpful it can be: we're able to get the surfactant in faster for these babies, and then they can get settled in without being disrupted again later. In our unit, we use LISA (Less Invasive Surfactant Administration) when we can. So it's starting to streamline things where we can say, this baby would benefit — let's do this now so we don't have to disturb them again in an hour or two.

We've actually started to see people reach out to us to do lung ultrasounds proactively. For instance, we had a 36-weeker in a lot of distress and an RT (Respiratory Therapist) came to me and said, "Could you do a lung ultrasound on this baby? I'm worried they might have signs of surfactant deficiency based on how they're looking right now." People are starting to recognize the benefit of getting surfactant to babies quicker, because really the nurses are the ones sitting at the bedside watching these babies in distress. I think they're noticing that we're starting to help some of these babies.

Srirupa (19:04.673) That's awesome. Share with us: what stage is the project at now, and when do we get to see the results of all of these QI initiatives?

Meghan Rowe (19:14.123) Great question. We're almost a year in, and we're hoping the educational module will constitute an additional PDSA cycle. This is going to be a QI project with a long course, but my hope is to get enough data together for an abstract. I'm hoping to present this at PAS in the coming year with solid, high-quality data at that point. I also think there are still a lot of improvements we can make to the process, so I'm hoping we continue to do additional cycles and keep improving, because I really think it's going to be helpful for all the babies in our unit and for continuing to show people how useful point-of-care ultrasound can be.

Srirupa (20:18.978) I appreciate that you're working on an educational module because I think it would be helpful not just in your institution but nationally. Lung ultrasound is something radiologists don't do that often, and so we as neonatologists have really self-taught ourselves to understand the features of pneumothorax versus surfactant deficiency versus TTN. There's so much ongoing work with the chance to significantly improve our outcomes. I look forward to hearing your results at PAS and to seeing where this takes your career. Which brings me to two big things. I wanted to let our listeners know that Meghan received the ONTPD (Organization of Neonatal Training Program Directors) Fellowship Research Award — which is amazing. Meghan, I know that was not for this project, so could you share what the project was that earned you that recognition?

Meghan Rowe (21:15.415) Absolutely. The project I presented at PAS this past year was looking at ventilation for VLBW (Very Low Birth Weight) infants after intubation with and without the use of RSI (Rapid Sequence Intubation).

Our unit had started using rapid sequence intubation medications to improve the safety and effectiveness of our intubations. But there was a lot of hesitation from experienced providers about using both sedation and paralysis in small babies, with the fear that it would impact post-intubation ventilation. So we wanted to look at what the ventilation of these babies actually looked like. We were looking at PCO2 (Partial Pressure of Carbon Dioxide) levels before and after intubation, and we actually partnered with University of Colorado to include their data as well. It was really rewarding to do this project, because I had actually started collecting data on it during my residency when one of my current attendings, Dr. Sara Neches, was a fellow. So we were finally able to pull our data together to present.

Srirupa (22:35.116) That's amazing. What is the one piece of advice you would give to fellows listening who want to develop their research interest in POCUS and move forward in a POCUS career?

Meghan Rowe (22:51.413) I think exposure is the most important thing — and repetition. It's taken me some time to get really comfortable with the different types of exams. Lung ultrasound is one of the skills that's quicker to pick up on; the scoring has a bit more nuance. For performing different ultrasounds, it's really about taking opportunities even when you're not sure you're doing it perfectly. Just having more familiarity with it matters — looking at UVC (Umbilical Venous Catheter) lines, looking at the lungs, just trying to get the hands-on time.

It takes some time to feel like you're getting all the views you want, and that's okay. Cardiac is one of the harder exams and it's taken me a while, but I find that every single time I do it, I feel more and more comfortable. There are also great opportunities to do workshops — they're increasing in frequency across the country — and I've found those helpful for really dedicated time to review different types of POCUS exams. At those conferences I've learned new things and new applications that we hadn't yet brought to our institution. It's also a great time to meet other people interested in this field and gain new tips and tricks. Finding any opportunity you can for the exposure is the most important thing.

Srirupa (24:36.258) That's amazing. One last question: how do you anticipate this experience with POCUS shaping your career going forward?

Meghan Rowe (24:50.751) I've definitely been thinking about this a lot as I move into my third year of fellowship. I definitely want POCUS to be part of my clinical practice and hopefully something I can continue to teach. I'm hoping to be a strong advocate for POCUS and bring it to whatever unit I end up working in. I'm hoping I can help teach others who haven't yet learned or who are early in the process of learning POCUS, and show how helpful it can be as another part of our physical exam.

Srirupa (25:31.106) That's amazing. I look forward to the many, many things you're going to do in your future, Meghan. It's wonderful that you picked up this interest early in your career. We all need people who are POCUS enthusiasts, and it's wonderful that you're continuing to have that interest and do the work on it. It was a pleasure having you come on the show to talk about your POCUS interests and your project, and I'm sure you have a lovely career ahead of you. Thanks so much for joining us.

Meghan Rowe (26:02.699) Thank you so much for having me. I really appreciate the time.