Association of a quality improvement program with neonatal outcomes in extremely preterm infants: a prospective cohort study

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.Rates of neonatal mortality and morbidity have not improved substantially over the past decade, despite advances in neonatal and perinatal care.^1–3 To improve infant outcomes, quality improvement initiatives have been implemented in neonatal units, but their success has varied.^4–6 A common approach is to form collaborative neonatal networks and to use quality improvement methods to address variations in practice and outcomes.^7–9 Commonly used quality improvement methods include identifying the best available evidence, adapting practice change to the organization, collaborative learning, and audit and feedback of information implemented in iterative “plan, do, study, act” cycles.¹⁰We previously developed and tested the Evidence-based Practice for Improving Quality (EPIQ) in 12 neonatal units in a cluster randomized trial.¹¹ EPIQ is a multifaceted quality improvement approach that combines the best available evidence with institution-specific data to identify institution-specific needs. Sites targeting nosocomial infection achieved a 32% reduction in infections, and sites targeting bronchopulmonary dysplasia achieved a 15% reduction in that condition. Five units that did not participate formed a comparison group and showed no improvement for either outcome.¹¹In the current study, our objective was to assess the generalizability of EPIQ to other neonatal units in Canada and to determine any association with improvements in mortality and morbidity among preterm neonates born at less than 29 weeks gestational age.