Collaborative quality improvement to promote …

1 PapersCollaborative quality improvement to promote evidence basedsurfactant for preterm infants: a cluster randomised trialJeffrey D Horbar, Joseph H Carpenter, Jeffrey Buzas, Roger F Soll, Gautham Suresh, Michael B Bracken,Laura C Leviton, Paul E Plsek, John C SinclairAbstractObjectiveTo test a multifaceted Collaborative qualityimprovement intervention designed to promote evidence basedsurfactant treatment for preterm infants of 23-29 weeks randomised controlled trialSetting and participants114 neonatal intensive care units(which treated 6039 infants of 23-29 weeks gestation born in2001).

2 Main outcome measuresProcess of care measures: proportionof infants receiving first surfactant in the delivery room,proportion receiving first surfactant more than two hours afterbirth, and median time from birth to first dose of outcomes: death before discharge home, Collaborative quality improvementadvice including audit and feedback, evidence reviews, aninteractive training workshop, and ongoing faculty support viaconference calls and with those in control hospitals, infants inintervention hospitals were more likely to receive surfactant inthe delivery room (adjusted odds ratio (95% confidenceinterval to )), were less likely to receive the first dosemore than two hours after birth (adjusted odds ratio ( ))

3 , and received the first dose of surfactant sooner afterbirth (median of 21 minutesv78 minutes, P < ). Theintervention effect on timing of surfactant was larger for infantsborn in the participating hospitals than for infants transferredto a participating hospital after birth. There were no significantdifferences in mortality or multifaceted intervention including audit andfeedback, evidence reviews, quality improvement training, andfollow up support changed the behaviour of healthprofessionals and promoted evidence based services continue to show major gaps between routinepractice and what the research evidence suggests is optimalpatient neonatology, systematic reviews indicate thatprophylactic surfactant treatment of high risk preterm infantsreduces risk of death and pneumothorax by 40%.

4 And that earliertreatment is more effective than later thisevidence, few such infants routinely receive prophylacticsurfactant treatment, and many infants, particularly those born atoutlying hospitals, receive delayed strategies for promoting behaviour change andevidence based practice have been 8 Experience fromthe Vermont Oxford Network suggests that multidisciplinarycollaborative quality improvement based on four key habits (change, evidence based practice, systems thinking, and collabo-rative learning) modifies practice in neonatal intensive care units,improves clinical outcomes, and reduces therefore conducted a cluster randomised controlledtrial11to test whether teams in neonatal intensive care unitsexposed to a multifaceted Collaborative quality improvementintervention based on the four key habits would administer thefirst dose of surfactant sooner after birth.

5 And achieve improvedpatient outcomes for preterm infants of 23-29 weeks Oxford NetworkThe Vermont Oxford Network is a voluntary collaboration ofhealth professionals whose mission is to improve the quality andsafety of medical care for newborn infants and their families( ). The network maintains a database for verylow birthweight infants at member sizeAccording to network data for 1998, of very lowbirthweight infants at member hospitals received surfactant inthe delivery room (standard deviation of individual hospital pro-portions 21%), the median time to surfactant administration was105 minutes, and the infant mortality was (standarddeviation of individual hospital proportions ).

6 We set a sam-ple size of 55 hospitals in each of the two study arms beforestarting the trial to give 90% power (two sided = ) to detectan increase to in the proportion of infants receiving sur-factant in the delivery room (13% difference). This sample sizealso had 90% power to detect a 48 minute difference in mediantime to surfactant administration and 80% power to detect adecrease in mortality to (4% difference). We expected amortality difference of 4% if delivery room surfactant treatmentincreased by 60% and if relative risk of death for infants receivingthis treatment was conform to the cluster randomisation, power calculationsaccounted for both intrahospital and interhospital 14 Eligibility, enrolment, and randomisationOf the 300 North American hospitals in the Vermont OxfordNetwork, 178 were eligible to enter the trial and 114 enrolled (figParticipants in the Vermont Oxford Network.)

7 And details of the interventionworkshop appear on 1 of 7 BMJVOLUME 329 23 OCTOBER 2004 on 11 January 2019 by guest. Protected by : first published as on 28 October 2004. Downloaded from 1). A secure computer program assigned enrolled hospitals toone of two study arms using a completely randomised were concealed from investigators except for JDH,who notified hospitals in writing on 24 May 2000. Other investi-gators learnt the identity of the intervention hospitals at theworkshop (see below).Components of the multifaceted interventionAudit and feedback In July 2000 intervention hospitalsreceived confidential, individualised feedback from the VermontOxford Network including site-specific information and peercomparisons related to the administration and timing ofsurfactant, and delivery room practice for infants of 23-29 weeks gestation born in 1998 and Intervention hospitals were invited to attend aworkshop held from 16 to 18 September 2000 (see details ofworkshop on ).

8 Of the 57 teams invited, 56 attended (53physicians, 46 nurses, and 21 respiratory therapists). Theworkshop included didactic sessions, facilitated site teamexercises, and multi-institutional group exercises designed topromote four key habits (change, evidence based practice,systems thinking, and Collaborative learning).915 Ongoing support Collaboration among intervention armteams was fostered through quarterly conference calls and anemail discussion hospitals received centre-specific, confidentialreports routinely prepared for members of the Vermont measuresPrimary outcome measures consisted of process of caremeasures (surfactant treatment in the delivery room, firstsurfactant treatment more than two hours after birth (amongthose receiving surfactant), and time after birth when firstsurfactant dose was administered)

9 And infant outcome measures(death before discharge from hospital and pneumothorax).Secondary outcome measures, identified before the trialstarted, included common morbidities23and co-interventionsfor preterm infants (see table 5 for details).Statistical methodsThe baseline year for comparing the two study arms began 25 May 1999. We assessed outcomes for infants born in 2001 (1 January to 31 December) with gestational ages of 23 weeks 0days to 29 weeks 6 days, with birth weights of 401 to 1500 g, andwithout major birth defects. We pre-specified conductingprimary analyses among all infants, and separately amonginfants born in the participating hospitals (inborn) and amonginfants transferred to a participating hospital after birth(outborn).

10 Our analyses were on an intention to treat basis. We analysedprimary and secondary dichotomous outcomes using logisticregression. Generalised estimating equations accounted forwithin-hospital adjusted analyses for infantcovariates (gestational age, birth location, ethnicity) and hospitalcovariates (type of neonatal intensive care unit, teaching status,and annual volume of infant patients).We used a log rank test with adjustment for clustering to testdifferences in time to administration of surfactant. We used pro-portional hazards models, accounting for clustering, adjusted forinfant and hospital covariates to calculate adjusted hazard ratios(ratios > 1 indicate earlier surfactant).