A Cluster-Randomized Trial of Benchmarking and Multimodal Quality Improvement to Improve Rates of Survival Free of Bronchopulmonary Dysplasia for Infants With Birth Weights of Less Than 1250 Grams

OBJECTIVE. We tested whether NICU teams trained in benchmarking and quality improvement would change practices and improve rates of survival without bronchopulmonary dysplasia in inborn neonates with birth weights of <1250 g. METHODS. A cluster-randomized trial enrolled 4093 inborn neonates with birth weights of <1250 g at 17 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Three centers were selected as best performers, and the remaining 14 centers were randomized to intervention or control. Changes in rates of survival free of bronchopulmonary dysplasia were compared between study year 1 and year 3. RESULTS. Intervention centers implemented potentially better practices successfully; changes included reduced oxygen saturation targets and reduced exposure to mechanical ventilation. Five of 7 intervention centers and 2 of 7 control centers implemented use of high-saturation alarms to reduce oxygen exposure. Lower oxygen saturation targets reduced oxygen levels in the first week of life. Despite these changes, rates of survival free of bronchopulmonary dysplasia were all similar between intervention and control groups and remained significantly less than the rate achieved in the best-performing centers (73.3%). CONCLUSIONS. In this cluster-randomized trial, benchmarking and multimodal quality improvement changed practices but did not reduce bronchopulmonary dysplasia rates.

[1]  L. Papile,et al.  Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. , 1978, The Journal of pediatrics.

[2]  Isaac Ben-Sira,et al.  An international classification of retinopathy of prematurity. Clinical experience. , 1985, Ophthalmology.

[3]  A. Detsky,et al.  When was a "negative" clinical trial big enough? How many patients you needed depends on what you found. , 1985, Archives of internal medicine.

[4]  Robert M. Kliegman,et al.  Necrotizing Enterocolitis: Treatment Based on Staging Criteria , 1986, Pediatric Clinics of North America.

[5]  K Y Liang,et al.  An overview of methods for the analysis of longitudinal data. , 1992, Statistics in medicine.

[6]  M. Gail,et al.  Aspects of statistical design for the Community Intervention Trial for Smoking Cessation (COMMIT). , 1992, Controlled clinical trials.

[7]  S. Goodman,et al.  The Use of Predicted Confidence Intervals When Planning Experiments and the Misuse of Power When Interpreting Results , 1994, Annals of Internal Medicine.

[8]  S M Shortell,et al.  The Performance of Intensive Care Units: Does Good Management Make a Difference? , 1994, Medical care.

[9]  A. Mancini,et al.  Topical ointment therapy benefits premature infants. , 1996, The Journal of pediatrics.

[10]  M. Hack,et al.  Hospitalization as a measure of morbidity among very low birth weight infants with chronic lung disease. , 1996, The Journal of pediatrics.

[11]  CENTER DIFFERENCES IN SURVIVAL WITHOUT CHRONIC LUNG DISEASE (CLD) IN VERY-LOW-BIRTH-WEIGHT (VLBW) INFANTS ARE NOT EXPLAINED BY POPULATION DIFFERENCES, OR THE PRESENCE AND EARLY MANAGEMENT OF RESPIRATORY DISTRESS SYNDROME (RDS) • 1524 , 1997, Pediatric Research.

[12]  Arthur S Slutsky,et al.  Injurious ventilatory strategies increase cytokines and c-fos m-RNA expression in an isolated rat lung model. , 1997, The Journal of clinical investigation.

[13]  Diane P. Martin,et al.  A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines? , 1998, The Joint Commission journal on quality improvement.

[14]  J. Tyson,et al.  Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. , 1998, American journal of obstetrics and gynecology.

[15]  H. Hummler,et al.  Delivery Room Management of Extremely Low Birth Weight Infants: Spontaneous Breathing or Intubation? , 1999, Pediatrics.

[16]  P. Plsek.  Innovative Thinking for the Improvement of Medical Systems , 1999, Annals of Internal Medicine.

[17]  D. Carlton,et al.  Chronic lung injury in preterm lambs. Disordered respiratory tract development. , 1999, American journal of respiratory and critical care medicine.

[18]  Innovative Thinking for the Improvement of Medical Systems , 1999 .

[19]  B. Vohr,et al.  Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. , 2000, Pediatrics.

[20]  E. Bell,et al.  Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. , 2011, The Cochrane database of systematic reviews.

[21]  L. Solberg,et al.  Failure of a continuous quality improvement intervention to increase the delivery of preventive services. A randomized trial. , 2000, Effective clinical practice : ECP.

[22]  L. Kohn,et al.  COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA , 2000 .

[23]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[24]  M. Moore,et al.  Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? The Neonatology Committee for the Developmental Network. , 2000, Pediatrics.

[25]  M. Davies,et al.  Permissive hypercapnia for the prevention of morbidity and mortality in mechanically ventilated newborn infants. , 2001, The Cochrane database of systematic reviews.

[26]  D. Henderson-smart,et al.  Restricted versus liberal oxygen exposure for preventing morbidity and mortality in preterm or low birth weight infants. , 2001, The Cochrane database of systematic reviews.

[27]  C R Bauer,et al.  Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. , 2001, Pediatrics.

[28]  V. Flenady,et al.  Tracheal suctioning without disconnection in intubated ventilated neonates. , 2001, The Cochrane database of systematic reviews.

[29]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[30]  Paul E. Plsek,et al.  Collaborative Quality Improvement for Neonatal Intensive Care , 2001 .

[31]  J J Allison,et al.  Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial. , 2001, JAMA.

[32]  A. Jobe,et al.  Antenatal infection/inflammation and postnatal lung maturation and injury , 2001, Respiratory research.

[33]  H. Aly.  Nasal prongs continuous positive airway pressure: a simple yet powerful tool. , 2001, Pediatrics.

[34]  G. Escobar,et al.  SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores. , 2001, The Journal of pediatrics.

[35]  E. Bell,et al.  Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. , 2014, The Cochrane database of systematic reviews.

[36]  W. McGuire,et al.  Formula milk versus preterm human milk for feeding preterm or low birth weight infants. , 2001, The Cochrane database of systematic reviews.

[37]  A. Jobe,et al.  Postnatal Lung Inflammation Increased by Ventilation of Preterm Lambs Exposed Antenatally to Escherichia coli Endotoxin , 2002, Pediatric Research.

[38]  Robert Parrish,et al.  Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative. , 2002, JAMA.

[39]  L. Irwig,et al.  Oxygen-saturation targets and outcomes in extremely preterm infants. , 2003, The New England journal of medicine.

[40]  E. DeLong,et al.  Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: a randomized controlled trial. , 2003, Journal of the American Medical Association (JAMA).

[41]  A. Greiner,et al.  Health Professions Education: A Bridge to Quality , 2003 .

[42]  A. Taddio,et al.  Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit. , 2003, The Cochrane database of systematic reviews.

[43]  Ann C. Greiner,et al.  Health Professions Education: A Bridge to Quality , 2004 .

[44]  P. Plsek,et al.  Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial , 2004, BMJ : British Medical Journal.

[45]  B. Vohr,et al.  Center differences and outcomes of extremely low birth weight infants. , 2004, Pediatrics.

[46]  M. Walsh,et al.  Impact of a Physiologic Definition on Bronchopulmonary Dysplasia Rates , 2004, Pediatrics.

[47]  R. Soll,et al.  The effect of prophylactic ointment therapy on nosocomial sepsis rates and skin integrity in infants with birth weights of 501 to 1000 g. , 2004, Pediatrics.

[48]  Paul D Cleary,et al.  Effects of a Quality Improvement Collaborative on the Outcome of Care of Patients with HIV Infection: The EQHIV Study , 2004, Annals of Internal Medicine.

[49]  E. Wagner,et al.  A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study. , 2004, Archives of pediatrics & adolescent medicine.

[50]  Harlan M Krumholz,et al.  Quality Improvement Efforts and Hospital Performance: Rates of Beta-Blocker Prescription After Acute Myocardial Infarction , 2005, Medical care.

[51]  L. Monte,et al.  [Bronchopulmonary dysplasia]. , 2005, Jornal de pediatria.

[52]  S. Kazzi,et al.  Oxygen Delivery Through Nasal Cannulae to Preterm Infants: Can Practice Be Improved? , 2005, Pediatrics.

[53]  Y. Han,et al.  Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2005, Pediatrics.

[54]  P. Davis,et al.  Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants. , 2005, The Cochrane database of systematic reviews.

[55]  Robert M Wachter,et al.  Expected and unanticipated consequences of the quality and information technology revolutions. , 2006, JAMA.

[56]  K. Shojania,et al.  Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. , 2006, JAMA.

[57]  E. Svensen,et al.  Prophylactic versus Selective Use of Surfactant in Preventing Morbidity and Mortality in Preterm Infants , 2012, Neonatology.