The quest for sustained multiple morbidity reduction in very low-birth-weight infants: the Antifragility project

Abstract

Objective:Can a comprehensive, explicitly directive evidence-based guideline for all therapies that might affect the major morbidities of very low-birth-weight (VLBW) infants help a neonatal intensive care unit (NICU) further improve generally favorable morbidity rates? Can Antifragility principles of provider adaptive growth from stressors, enhanced infant risk assessment and adherence to effective therapies minimize unproven treatments and reduce all morbidities?Study Design:Prospectively planned observational trial in VLBW infants: control group born October 2011 to September 2013 and study group October 2013 to September 2015. Multi-disciplinary evidence-based review assigned all NICU treatments into one of four distinct categories: (1) always employ this therapy for VLBW infants, (2) never use this therapy, (3) employ this questionable therapy thoughtfully, only in certain circumstances and (4) this therapy has insufficient evidence of efficacy and safety. Extensive staff education emphasized evidence-based potentially better practice (PBP) selection with compliance checks, appreciation of intertwined co-morbidities and prioritizing infant risk reduction strategies.Results:Control included 221 infants, mean (s.d.) age 29 (2.6) weeks, birth weight 1129 (257) g and Study included 197 infants, 29 (2.7) weeks, 1093 (292) g. One hundred and four distinct therapies were placed into categories 1 to 4, with 32 specific compliance checks. Overall mean compliance with the process checks during the second era was 70%, high: 100% (exclusive breast milk use), low: 24% (correct pulse oximetry alarm settings). Morbidity and mortality rates did not significantly change during the second era.Conclusions:In our NICU with favorable morbidity rates, an expanded effort using a comprehensive therapy guideline for VLBW infants did not further improve outcomes. We need deeper understanding of continuous quality improvement (CQI) fundamentals, therapy compliance, co-morbidity relationships and enhanced sensitivity of risk assessment. Our innovative Antifragility PBP guideline could be useful to other NICUs seeking improvement in VLBW infant morbidities, as we offer a reasoned and concise template of a broad array of therapies categorized efficiently for transparency and review, designed to enhance responsible CQI decision-making.

Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns

“…Because evidence‐based gold standards like randomised controlled trials cannot solve all conundrums, effective quality improvement productive of superior health and value is a compelling moral and financial imperative . Quality improvement collaboratives have documented significant mortality and morbidity reduction in premature infants , but difficulties persist (i) most of the morbidity reduction is in 28‐ to 32‐week infants, ELGANs have resisted improvement, (ii) while certain morbidity rates have declined (any late infection, retinopathy of prematurity, poor growth), other maladies show modest progress (severe intraventricular haemorrhage, necrotising enterocolitis), or have not improved (chronic lung disease), (iii) twofold to fourfold variation in morbidity rates persist within formal collaboratives despite shared tools, (iv) most publications highlight just one morbidity and do not employ risk‐adjusted composite outcomes and (v) detailed compliance with evidence‐based potentially better practices, resource utilisation and long‐term outcomes are seldom provided .…”

“…Inconstant quality improvement progress results from (i) inherent population differences, (ii) inability to sustain commitment to shared processes and outcomes, (iii) uneven execution of potentially better practices, including some with limited supportive evidence, (iv) financial and time constraints, (v) lack of understanding of human factors and culture and (vi) biologic limits of extreme prematurity . Our 10 NICU alliance (named the “Pod”) is an established subgroup within the Vermont Oxford Network Newborn Improvement Collaborative for Quality.…”

Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units

“…However, several complex challenges remain: (A) the twofold to fourfold variation in top and bottom quartiles for major morbidities like stages 3–4 retinopathy of prematurity and chronic lung disease persists despite ready availability of CQI tools for all,17 (B) NICUs endorse PBPs but do not consistently document compliance with such, making it difficult to ascertain cause and effect,18 (C) some important morbidities resist traditional CQI methodology (chronic lung disease and necrotising enterocolitis), suggesting crucial biological, cognitive and/or cultural limitations are yet to be elucidated1 and (D) value (health benefit divided by cost) is infrequently reported in CQI publications, adding to the perplexity of astute resource utilisation in this era of increasing financial constraints 3 17 18…”

Paving New Roads Towards Biodiversity-Based Drug Development in Brazil: Lessons from the Past and Future Perspectives

“…A simple demonstration of antifragility can be given by the stress suffered by the muscle fibers during lifting weights: the body adapts to lift heavier weights subsequently. To date, the concept has been mainly applied to computer science, economics, and management, with a few applications in medicine (Kaempf et al 2017;Fiorini et al 2015;Fatovich 2021). Taleb (2018) applied risk analysis to medical problems through the properties of nonlinear responses and described "antifragility" as a mathematical property for local convex response and "fragility" as its opposite, locally concave (Fig.…”