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Clinical Trial
. 2004 Oct 30;329(7473):1004.
doi: 10.1136/bmj.329.7473.1004.

Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial

Jeffrey D Horbar  1 , Joseph H Carpenter, Jeffrey Buzas, Roger F Soll, Gautham Suresh, Michael B Bracken, Laura C Leviton, Paul E Plsek, John C Sinclair
Affiliations
Clinical Trial

Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial

Jeffrey D Horbar et al. BMJ. .

Abstract

Objective: To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation.

Design: Cluster randomised controlled trial.

Setting and participants: 114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001).

Main outcome measures: Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax.

Intervention: Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email.

Results: Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax.

Conclusion: A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.

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Figures

Fig 1
Fig 1
Flow of participants through study. Of 300 North American hospitals in the Vermont Oxford Network, 178 had neonatal units eligible to participate and 114 of these enrolled in the study
Fig 2
Fig 2
Median (interquartile range) time after birth at which first dose of surfactant was administered to preterm infants in neonatal intensive care units by calendar quarter. Units in intervention group were notified of their status in May 2000, were given individualised feedback in July 2000, and were invited to a quality improvement workshop in September 2000
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References

    1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press, 2001.
    1. Soll RF, Morley CJ. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2001;(2): CD000510. - PubMed
    1. Yost CC, Soll RF. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev 2000;(2): CD001456. - PubMed
    1. Horbar JD, Carpenter J, Buzas J, Soll RF, Suresh G, Bracken MB, et al. Timing of initial surfactant treatment for infants 23 to 29 weeks gestation: is routine practice evidence based? Pediatrics. 2004;113: 1593-602. - PubMed
    1. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2003;(3): CD000259. - PubMed

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