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PEDIATRICS Vol. 107 No. 1 January 2001, pp. 14-22

Collaborative Quality Improvement for Neonatal Intensive Care

Received Apr 21, 2000; accepted Aug 16, 2000.

Jeffrey D. Horbar*, Jeannette RogowskiDagger , Paul E. Plsek§, Paula Delmoreparallel , William H. Edwards, James Hocker#, Anand D. Kantak**, Patrick LewallenDagger Dagger , William Lewis§§, Eugene Lewit||, Connie J. McCarroll¶¶, Dennis Mujsce##, Nathaniel R. Payne***, Patricia Shiono||, Roger F. Soll*, Kathy Leahy*, Joseph H. Carpenter*, and for the NIC/Q Project Investigators of the Vermont Oxford Network

From the * University of Vermont College of Medicine and Vermont Oxford Network, Burlington, Vermont; Dagger  Rand Corporation, Washington, DC; § Paul E. Plsek and Associates, Inc, Roswell, Georgia; parallel  Wesley Medical Center, Wichita, Kansas;  Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; # The Children's Hospital of Illinois, Peoria, Illinois; ** Children's Hospital Medical Center of Akron, Akron, Ohio; Dagger Dagger  Legacy Emanuel Hospital and Health Center, Portland, Oregon; §§ Parkview Memorial Hospital, Fort Wayne, Indiana; || David and Lucile Packard Foundation, Los Altos, California; ¶¶ Miami Valley Hospital, Dayton, Ohio; ## Milton S. Hershey Medical Center, Hershey, Pennsylvania; and *** Children's Health Care-Minneapolis, Minneapolis, Minnesota.

Objective.  To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model.

Design.  Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997.

Setting.  Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group.

Patients.  Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738).

Interventions.  NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits.

Main Outcome Measures.  The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g.

Results.  Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997.

Conclusion.  We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.  Key words:  collaborative quality improvement, neonatal intensive care, infection, chronic lung disease.




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