Impact of 9 Years with NICQ

Payne NR, Finkelstein MJ, Liu M, Kaempf JW, Sharek PJ, Olsen S. NICU Practices and Outcomes Associated with 9 Years of Quality Improvement Collaboratives. Pediatrics published online Feb. !, 2010; DOI: 10. 1542/peds.2009-1272. Pubmed Abstract PDF (Full Text)

OBJECTIVE Quality improvement collaboratives (QICs) can improve short-termoutcomes, but few have examined their long-term results. Thisstudy evaluated the changes in treatment practices and outcomes associated with participation in multiple sequential QICs.

DESIGN AND METHODS This retrospective, 9-year, pre-post study of very low birthweight infants, we assessed treatment and outcomes from the8 NICUs of the Reduce Lung Injury (ReLI) group of a QIC sponsoredby the Vermont Oxford Network (VON). We analyzed data from 1998(pre-ReLI), 2001 (last ReLI year), and 2006 (5 years after ReLI)by using univariate and multiple regression.

RESULTS A total of 4065 very low birth weight infants were treated inReLI NICUs in 1998, 2001, and 2006. From 1998 to 2006, the ReLIgroup decreased delivery room intubation (70% vs 52%; adjusted odds ratio [aOR]: 0.2 [95% confidence interval (CI): 0.2–0.3];P < .001), conventional ventilation (75% vs 62%; aOR: 0.3[95% CI: 0.2–0.4]; P < .001), and postnatal steroidsfor BPD (35% vs 10%; aOR: 0.09 [95% CI: 0.07–0.1]; P< .001). They increased the use of nasal continuous positiveairway pressure (57% vs 78%; aOR: 3.3 [95% CI: 2.7–3.9];P < .001). BPD-free survival remained unchanged (68% vs 66%;aOR: 0.9 [95% CI: 0.7–1.1]; P = .16), the BPD rate increased(25% vs 29%; aOR: 1.3 [95% CI: 1.1–1.6]; P = .017), survivalto discharge increased (90% vs 93%; aOR: 1.5 [95% CI: 1.1–2.2];P < .001), and nosocomial infections decreased (18% vs 15%;aOR: 0.8 [95% CI: 0.6–0.99]; P = .045).

CONCLUSIONS Participation in VON–sponsored QICs was associated withsustained implementation of potentially better respiratory practices,increased survival, and reduced nosocomial infections. The BPD-freesurvival rate did not change, and the BPD rate increased. Implemented changes endured for at least 5 years after the QIC.

Comments: Rob Payne and some of our other NICQ friends have published an interesting report about the enduring effects of participation in NICQ collaboratives. Many of us (including our administrators) wonder whether being part of NICQ truly translates into improved outcomes for our patients and families. From this report, it appears that centres participating in the ReLI collaborative group of NICQ 2000 were able to successfully change practice by implementing a group of PBPs developed to reduce lung injury and BPD. The effect was sustained well beyond the end of their involvement with this collaborative but a reduction in BPD did not occur. However, similar to findings in the EPIQ study described in a previous Neonotes posting, participating centers saw improvements in other parameters that were not specifically targeted (neonatal mortality and nosocomial infection). Why did successful implementation of the PBPs not result in a reduction in the incidence of BPD? Several points deserve comment:

The definition of BPD remains problematic. Need for supplemental oxygen at 36 weeks CGA remains relatively imprecise in identifying preterm infants with true chronic lung disease. Adding to the problem of identifying infants with this morbidity is the need to use an algorithm to account for infants that are transferred prior to 36 weeks. If a more robust definition could have been used, such as that proposed by the NICHD network, it is possible that a difference could have been appreciated.
The authors observe that, in contrast to ReLI, the Breathsavers collaborative group of NICQ 2002 was able to successfully reduce BPD (link to publication) and suggest that either their PBPs may have been more germaine or that the centers were able to make cultural changes necessary to allow the PBPs to work. As the authors state, "Organizational strategies aimed at improving NICU caregivers' ability to work collaboratively may be as important as the specific PBPs."
I have always been puzzled by the inclusion of the PBP to reduce post-natal steroid exposure as part of the bundle of PBPs designed to reduce BPD. There was a profound reduction in the use of post-natal steroids over the 9 year study period and this would be expected to increase the incidence of BPD. This could very well have counterbalanced the protective effects of the other PBPs. Perhaps the most important benefit was that a marked reduction in the use of post-natal steroids was achieved in ReLI centres with improved survival and only a modest increase in BPD (as reported in a previous publication by Joe Kaempf and colleagues).

The authors also point out the influence that many of these QICs have had on the broader neonatal community. One very nice phrase from the discussion struck a chord: "The VON is more than a database. It has become a vast social network for quality improvement with many online and informal communities." Michael Dunn

Feb 20, 2009
01:10 AM

I agree with Michael ... especially the part about the importance of implementing practices that have good evidence to support them. Based on the information available at the time, the ReLI group focused mainly on avoiding intubation and increasing CPAP use to avoid CLD. We now know from the COIN trial (see 9-018) that the Early CPAP strategy is no better than early intubation and surfactant in avoiding the combined outcome of death or CLD, We learned at the Hot Topics conference in 2009 that the VON Early Delivery Room Management Trial (comparing Early CPAP to in-and-out surfactant to early intubation and ventilation) showed no difference in outcomes between groups (results not yet published). So perhaps a major reason for their lack of success at reducing CLD was related to lack of availability of good data at the time.

At Baptist Children's Hospital in Miami, we have enjoyed much better success at CLD prevention. After participating in the BreathSavers focus group in NICQ 2005, we have seen our CLD rate fall from about 50% to about 10%. Some of the PBPs that we implemented include Vitamin A prophylaxis, Oxygen saturation range targeting, Room air Trials at 32, 34 and 36 weeks, and Early Caffeine prophylaxis. Most (if not all) of these practices are supported by Level I or Level 2 evidence. I also believe that giving "ownership" of this project to our respiratory therapists was a large part of our success. I'd be interested in hearing from other NICUs who have had success at reducing CLD. What were the keys to your success?

Andy Kairalla MD
Baptist Children's Hospital
Miami FL