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Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised
Jeffrey D Horbar1, Joseph H Carpenter, Jeffrey Buzas
1Vermont Oxford Network, 33 Kilburn Street, Burlington, VT 05401, USA. horbar@vtoxford.org
Insights
A quality improvement intervention significantly improved evidence-based surfactant treatment for preterm infants, ensuring timely administration. This initiative enhanced surfactant delivery practices without impacting infant mortality or pneumothorax rates.
Area of Science:
- Neonatal Medicine
- Quality Improvement Science
- Evidence-Based Practice
Background:
- Preterm infants (23-29 weeks gestation) require timely surfactant treatment for respiratory distress syndrome.
- Variability exists in the administration of evidence-based surfactant therapy in neonatal intensive care units.
- Optimizing surfactant treatment is crucial for improving outcomes in extremely preterm infants.
Purpose of the Study:
- To evaluate a multifaceted collaborative quality improvement intervention aimed at promoting evidence-based surfactant treatment.
- To assess the impact of the intervention on the timing and process of surfactant administration in preterm infants.
- To determine if the intervention influenced clinical outcomes such as mortality and pneumothorax.
Main Methods:
- A cluster randomized controlled trial involving 114 neonatal intensive care units and 6039 infants (23-29 weeks gestation).
- The intervention included audit and feedback, evidence reviews, training workshops, and ongoing faculty support.
- Process measures focused on surfactant delivery timing (delivery room, >2 hours post-birth), and clinical outcomes included mortality and pneumothorax.
Main Results:
- Infants in intervention hospitals were significantly more likely to receive surfactant in the delivery room (aOR 5.38).
- The intervention reduced the likelihood of delayed surfactant administration (>2 hours post-birth) (aOR 0.35) and decreased median time to first dose (21 vs. 78 minutes).
- No significant differences were observed in mortality before discharge or pneumothorax rates between groups.
Conclusions:
- A multifaceted quality improvement intervention effectively changed healthcare professional behavior.
- The intervention successfully promoted evidence-based surfactant treatment practices for preterm infants.
- The study demonstrates the feasibility and impact of collaborative quality improvement in neonatal care.
Objective:
To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation.
Design:
Cluster randomised controlled trial.
Setting And Participants:
114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001).
Main Outcome Measures:
Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax.
Intervention:
Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email.
Results:
Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax.
Conclusion:
A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.
