Show me the Evidence

Fall 2012
Volume 1, Issue 3

[ Table of Contents ]

EPIQ Results: Reconfiguring Neonatal Care Saves More Preterm Babies from Disability and Death

Model of care now used internationally

At a Glance

Who: Dr. Shoo K. Lee, University of Toronto

Issue: Preterm babies are at greater risk of death and disabilities and account for a disproportionately high share of hospitals’ postnatal care costs.

Project: Dr. Lee began what eventually became EPIQ (Evidence-Based Practice of Improving Quality) in 2002 to reduce rising rates of nosocomial (hospital-acquired) infections and a lung disease called bronchopulmonary dysplasia (BPD). It was followed by a three-year effort to apply EPIQ strategies across Canada and by EPIQ II, which targets additional preterm health threats.

Research Evidence: A randomized controlled trial at 12 Canadian neonatal intensive care units (NICUs) reduced nosocomial infections by 44% and BPD by 15%, a cost savings of almost $2,500 per patient. A study found the improvements in the NICUs were sustained two years afterwards. Early results from EPIQ II indicate reductions in other diseases as well.

Evidence in Action: EPIQ is currently operational in 30 NICUs across Canada, helping to craft and implement continuous quality improvement practices. Internationally, the EPIQ model has been adopted by six Latin American countries, 38 NICUs in Malaysia and is being piloted in China.

Sources: Lee et al. the EPIQ Trial: Reduction in Nosocomial Infection and Bronchopulmonary Dysplasia were Sustained 2 years After the Trial, poster presentation at pediatric academic societies conference 2010.

The 1990s was not a good decade for preterm babies in Canadian hospitals, according to Dr. Shoo K. Lee, who was then working at the Children’s & Women’s Health Centre of British Columbia. “We were seeing very little improvement in outcomes,” says Dr. Lee, who is now at the University of Toronto and leads pediatric and neonatal programs at three hospitals. “We made huge advances from about 1960 to 1990, but it had plateaued. If anything, it might actually have gotten worse.”

At the same time, says Dr. Lee, the patient load had increased by over 30%, largely because more women were having children later in life and many were using in vitro fertilization to get pregnant – two factors linked to higher incidence of preterm births.

“Some experts thought we had reached the limits of neonatal technology, that until we got the next jump forward we were not going to see much improvement. Well, what were we going to do in the meantime, sit on our backsides? We had to do better. That’s how it got started.”

The “it” Dr. Lee refers to is the Canadian Neonatal Network. Created in 1995, the Network focuses on ways to improve the health and treatment of newborns in hospitals, especially those in neonatal intensive care units (NICUs). Such babies are at a high risk for nosocomial (hospital-acquired) infections and a chronic lung disease linked to ventilator use called bronchopulmonary dysplasia (BPD). As well, NICU care is expensive: babies born at less than 28 weeks gestation have average hospital costs of $84,235, compared to $1,050 for full-term babies.

With CIHR funding, Dr. Lee and the Network’s experts built a database to track neonatal care across Canada that showed significant variations in practices and outcomes.

“There were strengths and weaknesses across the country,” says Dr. Lee. “We said, ‘OK, now that we know that some of us do certain things better than others, how do we make changes?’”

Dr. Lee, who has a background in economics, championed the use of the continuous quality improvement (CQI) model. In the manufacturing sector, CQI stresses the need to constantly evaluate and refine processes to better serve clients and reduce production costs. However, realizing that a model for producing better widgets is not directly applicable to doing a better job of saving preterm babies’ lives, “we brought evidence into CQI,” says Dr. Lee. “It’s called Evidence-Based Practice for Improving Quality (EPIQ).”

In essence, EPIQ helps hospitals create teams of neonatologists, nurses, respiratory therapists, research assistants, dieticians and other experts and trains them to gather and analyze data, target specific practices or processes, and work with front-line NICU staff to make changes.

How EPIQ works: Evidence + Culture Change

EPIQ works by combining a focus on the collection and analysis of data about care in NICUs, with tools for helping facilitate cultural changes within health care centres. For example, EPIQ experts train teams to conduct evidence reviews, gather and analyze data, create and refine process-of-care maps, manage change and measure outcomes. The in-house team also collects data that EPIQ experts benchmark against other hospitals and use to identify processes with poor outcomes. At the same time, EPIQ experts visit hospitals and conduct staff interviews, focus groups and surveys to assess organizational structure and culture and identify potential barriers to change. EPIQ provides funding for a coordinator to champion changes in practice, train staff and ensure required materials and equipment are in place.

“We created the model and then we tested it with a two-year randomized controlled trial to prove it could work,” says Dr. Lee of the original study. “We took six hospitals and asked them to reduce BPD and another six hospitals and asked them to reduce nosocomial infections.”

From 2003 to 2005, the NICUs using the new model demonstrated a 44% decrease in the incidence of nosocomial infections and a 15% decrease in BPD, which translated into a reduction of NICU patient stays of almost two days and a cost saving of almost $2,500 per patient. If implemented nationally, the cost savings would amount to $7.5 million per year. A follow-up study found the improvements were sustained two years after the EPIQ trial with infection incidence decreasing further among several NICUs.

With funding from CIHR and the Michael Smith Foundation for Health Research, the Network produced guidelines based on the new model’s success with BPD and nosocomial infections and distributed them to all Canadian hospitals with NICUs.

However, says Dr. Lee, they soon discovered that creating and circulating guidelines is simply not enough. “The reality is, it’s not so easy for uptake to happen. Sometimes people just don’t believe the guidelines. Even when they do believe, sometimes they say, ‘It can’t be done here.’ There sometimes can be a leadership problem. There are many reasons why these things don’t happen.”

That realization led Dr. Lee and Network colleagues to create the CIHR-supported EPIQ II. This time, the team highlighted a specific set of challenges to be addressed and paid more attention to tools that would achieve the cultural changes necessary for successful implementation of the EPIQ model. EPIQ II has engaged all NICUs across Canada in a coordinated effort to improve outcomes in BPD and nosocomial infections and three other major conditions that afflict preterm babies: intraventricular hemorrhage (bleeding in the brain that can cause brain damage) necrotizing enterocolitis (a frequently deadly infection that kills intestinal tissue) and retinopathy of prematurity (abnormal blood vessel development in the retina that can lead to blindness).

Evidence in Action: Hospital-acquired infection rate cut by 30%.

Preliminary analysis of the first two years of EPIQ II shows the model is working: “We have reduced nosocomial infection rates across the country by 30%, retinopathy of prematurity by 20%, and necrotizing enterocolitis by 15%,” says Dr. Lee.

Dr. Eugene Ng has seen improvements occur at his NICU at Toronto’s Sunnybrook Health Sciences Centre where, from 2008 to 2010, NICU deaths dipped 75%, the incidences of retinopathy of prematurity and nosocomial infections were cut in half and BPD fell by 27%. While Dr. Ng cautions that moving Sunnybrook’s NICU from outdated quarters to a more spacious modern facility also had an important impact, he says quality improvement initiatives such as EPIQ have been a key driver in his hospital’s steep reduction in the incidence of preterm babies’ diseases. “The whole idea of EPIQ is to improve outcomes. We are seeing results, which is very encouraging.”


Evidence in Action: A model of care used internationally

The EPIQ model has been adopted by six Latin American countries – Argentina, Brazil, Chile, Colombia, Ecuador and Peru – and is in place at 38 NICUs in Malaysia.

The Foothills Medical Centre, meanwhile, was one of two NICUs in Canada to apply new evidence from EPIQ II to help reduce the incidence of necrotizing enterocolitis. “We were running at a 9% incidence rate in 2008–09 and we are now down to about 2.5%, says Dr. Wendy Yee, a staff neonatologist at Foothills. For us, it’s huge in terms of mortality and morbidity as well.” Dr. Yee attributes the remarkable reduction in the incidence of the disease directly to the hospital’s adoption of the EPIQ model. “It allows us to sustain practice changes, which is what really makes an impact in the long term.”

Other nations have noticed the remarkable improvements that Canadian NICUs have made over the past decade. According to Dr. Lee, the EPIQ model has been adopted by six Latin American countries – Argentina, Brazil, Chile, Colombia, Ecuador and Peru – and is in place at 38 NICUs in Malaysia. “Many countries are coming to us, saying ‘How are you doing this? We want to learn from you,’” says Dr. Lee. “We went to China and trained teams in several hospitals, helping them put an EPIQ system in place.”

Dr. Yun Cao, with the Children’s Hospital of Fudan University in Shanghai, says a multicentre trial is under way to implement EPIQ and improve outcomes. “So far, I only have results from our hospital, but from the data we can see a reduction of almost 50% in ventilator associated pneumonia. I want to do further study to see if we can reduce other complications as well.”

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