Lee SK, Aziz K, Singhal N et al.  Improving the quality of care for infants: a cluster, randomized controlled trial.  CMAJ 2009 Oct 13;181(8):469-76.  Full Text / PDF  / Commentary

 BACKGROUND: We developed and tested a new method, called the Evidence-based Practice for Improving Quality method, for continuous quality improvement.

METHODS: We used cluster randomization to assign 6 neonatal intensive care units (ICUs) to reduce nosocomial infection (infection group) and 6 ICUs to reduce bronchopulmonary dysplasia (pulmonary group). We included all infants born at 32 or fewer weeks gestation. We collected baseline data for 1 year. Practice change interventions were implemented using rapid-change cycles for 2 years.

RESULTS: The difference in incidence trends (slopes of trend lines) between the ICUs in the infection and pulmonary groups was - 0.0020 (95% confidence interval [CI] - 0.0007 to 0.0004) for nosocomial infection and - 0.0006 (95% CI - 0.0011 to - 0.0001) for bronchopulmonary dysplasia.

INTERPRETATION: The results suggest that the Evidence-based Practice for Improving Quality method reduced bronchopulmonary dysplasia in the neonatal ICU and that it may reduce nosocomial infection.

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Comments: This cluster RCT involving 11 NICUs in Canada from 2002-2005 demonstrated that BPD and NI could be reduced through the application of comprehensive QI methodology.  The EPIQ method involves “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.”  Obviously, EPIQ is a lot like NICQ although there are a couple of notable differences.  Firstly, in conjunction with the development of a list of “potentially useful practices” for reducing NI or BPD (it is interesting to compare and contrast these lists with those developed through the various VON NICQ collaboratives), a great deal of process and practice data were collected and analyzed to help reveal changes that would be most likely to result in improvements in each institution.  Secondly, there was support available from the coordinating centre for each site to receive communication tools, onsite coaching and real-time reports on their performance (process or outcome).  A large agency grant supported the study and each center had to fund the data abstraction.  The cluster randomized trial design (like the VON TRIP study) allowed the investigators to not only assess whether outcome would improve over time with participation but also whether there were differences between the groups working to improve each of the two morbidities.  As might be expected, infection rates improved in the infection group and BPD rates improved in the pulmonary group.  However, one of the more intriguing findings was that infection rates also improved in the BPD group.  There are several plausible explanations, including the Hawthorne effect and/or the tangential impact of lower levels of respiratory support (less time on ETT, fewer line days, better feeding tolerance, etc).  The authors speculate that, “Because quality improvement is about transforming behaviours, spill-over from one outcome to another may be expected.” Michael Dunn

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