Improving the quality of care for infants: a cluster randomized controlled trial

Abstract

A lthough methods for continuous quality improvement have been used to improve outcomes, 1-3 some, such as the National Institutes of Child Health and Human Development Quality Collaborative, 4 have reported little or no effect in neonatal intensive care units (ICUs). These methods have been criticized for being based on intuition and anecdotes rather than on evidence.5 To address these concerns, researchers have developed methods aimed at improving the use of evidence in quality improvement. Tarnow-Mordi and colleagues, 6 Sankaran and colleagues 7 and others [8][9][10] have used benchmarking instruments 6,8,11 to show risk-adjusted variations in outcomes in neonatal ICUs. Synnes and colleagues 12 reported that variations in the rates of intraventricular hemorrhage could be attributed to practice differences. MacNab and colleagues 13 showed how multi level modelling methods can be used to identify practice differences associated with variations in outcomes for targeted interventions and to quantify their attributable risks.Building on these results, we developed the Evidence-based Practice for Improving Quality method for continuous quality improvement. This method is based on 3 pillars: the use of evidence from published literature; the use of data from participating hospitals to identify hospital-specific practices for targeted intervention; and the use of a national network to share expertise. By selectively targeting hospital-specific practices for intervention, this method reduces the reliance on intuition and anecdotes that are associated with existing quality-improvement methods.Our objective was to evaluate the efficacy of the Evidencebased Practice for Improving Quality method by conducting a prospective cluster randomized controlled trial to reduce nosocomial infection and bronchopulmonary dysplasia among infants born at 32 or fewer weeks' gestation and admitted to 12 Canadian Neonatal Network hospitals 14 over a 36-month period. We hypothesized that the incidence of nosocomial infection would be reduced among infants in ICUs randomized to reduce infection but not among those in ICUs randomized to reduce bronchopulmonary dysplasia. We also hypothesized that the incidence of bronchopulmonary dysplasia would be reduced among infants in the ICUs randomized to reduce this outcome but not among those in ICUs randomized to reduce infections. Background: We developed and tested a new method, called the Evidence-based Practice for Improving Quality method, for continuous quality improvement.

Nosocomial Infection Reduction in VLBW Infants With a Statewide Quality-Improvement Model

“…54 In contrast, targeted neonatal collaboratives have consistently affected their targeted outcomes (age at surfactant administration 38,54 and nosocomial infection or centralline-associated bloodstream infection reduction). 38,39,56,57 Our study shows a positive effect on the outcome of interest, although we did not have access to corroborating process data and made no specific plans for follow-up.…”

Metrics for NICU antibiotic use: which rate is right?

“…Of course, if appropriate antibiotic treatment correlated perfectly with documented infection then the investigative focus would be directed toward variation in infection ratesFalready a subject of much scrutiny, including by neonatal collaboratives across North America. 5,7,9 Furthermore, as Wirtschafter et al 3 demonstrate, treatment of definitive infections represents the minority of antibiotic use in the NICU population.…”

The Canadian Preterm Birth Network: a study protocol for improving outcomes for preterm infants and their families

“…The CNN collects and maintains data from all 31 level 3 neonatal intensive care units in Canada and is used for benchmarking, collaborative research, quality improvement, training and advocacy. [3][4][5][9][10][11] Furthermore, robust linkages exist between the CNN and its associated databases: the Canadian Neonatal Follow-Up Network (www.cnfun.ca/), which includes 26 neonatal follow-up programs, the Canadian Neonatal Transport Network and the Canadian Pediatric Surgery Network (www.capsnetwork.org/). The CPTBN will incorporate all existing networks and will expand to include the maternal-fetal medicine/obstetrics community from 24 Canadian tertiary perinatal units ( Figure 2).…”

“…[3][4][5] Outcome improvements to date have used data platforms limited to neonatal and neonatal follow-up research 6,7 despite mounting evidence that events before and during pregnancy can have life-long implications for the child. 7,8 Furthermore, our platforms were missing data regarding family integration into preterm birth care, which can positively affect neonatal outcomes.…”

“…[3][4][5] To build on those improvements, the CPTBN protocol will expand the use of EPIQ methods to maternal-fetal medicine/obstetrics care practices and family-integrated care practices. Research…”