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Association of a quality improvement program with neonatal outcomes in extremely preterm infants: a prospective
Shoo K Lee1, Prakesh S Shah2, Nalini Singhal1
1Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man.
Insights
The Evidence-based Practice for Improving Quality (EPIQ) methodology successfully reduced mortality and major morbidities in very preterm infants across Canada. Infants born between 26-28 weeks gestational age showed the most significant improvements with EPIQ implementation.
Area of Science:
- Neonatal Medicine
- Pediatric Critical Care
- Quality Improvement Science
Background:
- Previous studies demonstrated the effectiveness of Evidence-based Practice for Improving Quality (EPIQ) in reducing bronchopulmonary dysplasia and nosocomial infections in preterm infants.
- This study evaluated the impact of a Canada-wide EPIQ implementation on mortality and morbidity in extremely preterm infants (less than 29 weeks gestational age).
Purpose of the Study:
- To assess the association between Canada-wide implementation of the Evidence-based Practice for Improving Quality (EPIQ) methodology and outcomes in preterm infants.
- To determine the impact of EPIQ on a composite outcome of neonatal mortality and major morbidities.
Main Methods:
- A prospective cohort study involving 6026 infants across 25 Canadian neonatal units from 2008 to 2012.
- Implementation of EPIQ followed a 1-year baseline and a 6-month training period, with data collected over 3 years.
- Multivariable analyses compared outcomes between the baseline period and year 3, focusing on a composite outcome and individual morbidities.
Main Results:
- The composite outcome of mortality and major morbidities significantly decreased from baseline to year 3 (70% vs. 65%; adjusted OR 0.63).
- Significant reductions were observed in severe retinopathy (17% vs. 13%; OR 0.60), necrotizing enterocolitis (10% vs. 8%; OR 0.73), and nosocomial infections (32% vs. 24%; OR 0.63).
- Infants born at 26 to 28 weeks gestational age experienced a greater reduction in the composite outcome (62% vs. 52%; OR 0.62), while those born at less than 26 weeks showed no significant benefit.
Conclusions:
- The Evidence-based Practice for Improving Quality (EPIQ) methodology proved generalizable across Canadian neonatal units.
- EPIQ implementation was associated with a significantly lower likelihood of the composite outcome, severe retinopathy, necrotizing enterocolitis, and nosocomial infections.
- Infants born at 26 to 28 weeks gestational age benefited most from the EPIQ intervention.
Background:
We previously demonstrated improvement in bronchopulmonary dysplasia and nosocomial infection among preterm infants at 12 neonatal units using the Evidence-based Practice for Improving Quality (EPIQ). In the current study, we assessed the association of Canada-wide implementation of EPIQ with mortality and morbidity among preterm infants less than 29 weeks gestational age.
Methods:
This prospective cohort study included 6026 infants admitted to 25 Canadian units between 2008 and 2012 (baseline year, n = 1422; year 1, n = 1611; year 2, n = 1508; year 3, n = 1485). Following a 1-year baseline period and 6 months of training and planning, EPIQ was implemented over 3 years. Our primary outcome was a composite of neonatal mortality and any of bronchopulmonary dysplasia, severe neurologic injury, severe retinopathy of prematurity, necrotizing enterocolitis and nosocomial infection. We compared outcomes for baseline and year 3 using multivariable analyses.
Results:
In adjusted analyses comparing baseline with year 3, the composite outcome (70% v. 65%; adjusted odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51 to 0.79), severe retinopathy (17% v. 13%; OR 0.60, 95% CI 0.45 to 0.79), necrotizing enterocolitis (10% v. 8%; OR 0.73, 95% CI 0.52 to 0.98) and nosocomial infections (32% v. 24%; OR 0.63, 95% CI 0.48 to 0.82) were significantly reduced. The composite outcome was lower among infants born at 26 to 28 weeks gestation (62% v. 52%; OR 0.62, 95% CI 0.49 to 0.78) but not among infants born at less than 26 weeks gestational age (90% v. 88%; OR 0.73, 95% CI 0.44 to 1.20).
Interpretation:
EPIQ methodology was generalizable within Canada and was associated with significantly lower likelihood of the composite outcome, severe retinopathy, necrotizing enterocolitis and nosocomial infections. Infants born at 26 to 28 weeks gestational age benefited the most.
