Changing the Paradigm of Neonatal Care Shoo Lee, MBBS, FRCPC, PhD Paediatrician-in-Chief, Mount Sinai Hospital; Professor of Paediatrics, Obstetrics & Gynecology, and Public Health, University of Toronto; Scientific Director, Institute of Human Development, Child & Youth Health, Canadian Institutes of Health Research

Conflict of Interest None to declare

Canadian Neonatal NetworkTM Founded 1995 Edmonton Quebec City St John’s Moncton Saskatoon Sherbrooke Victoria Calgary Fredericton Vancouver Regina Montreal Winnipeg St John New Westminster Ottawa Kingston Halifax Toronto London Hamilton “Improve care through research”

Neonatal Outcomes 1960-2000 1960-1985 1990-2000 Source: Congress of USA, Office of Tech Assessment, NTIS order #PB88-158902 4

EPIQ Conceptual Model Evidence Facilitation Context Published evidence Evidence reviews Clinical studies/trials Local data Best practice examples Practice guidelines Evidence Facilitation Context Process Data Outcomes Data Organizational culture Individual behavior Barriers to change Leadership Change management Facilitation tools

THE EPIQ PROJECT - Transforming Care through Clinical & Implementation Research Reduced Mortality, Morbidity and Hospital Length of Stay in Canadian Neonatal Intensive Care Units OBJECTIVE Reduce mortality, major morbidity and hospital length of stay in NICU Pilot project in 12 sites outlining new practices for care National scale-up of the new practices, implemented in 30 hospitals and 17 universities across Canada PROJECT OUTCOMES (3 years) 30% decrease in severe eye disease causing blindness 30% decrease in hospital acquired infection 30% decrease in severe intestinal infection with high mortality 2 days average reduction in length of hospital stay $7-10M annual cost savings Lee SK, Canadian Neonatal Network EPIQ Study Group, CMAJ 2009. DOI 10.1503/cmaj.081727

Family Integrated Care The Estonian Model

Post partum floor

Caring for Families Mothers health and wellbeing is considered essential to the baby’s wellbeing: - midwife - psychologist - physician Atmosphere of team support; Mother and baby are a unit, Nurse partners mother in the baby’s care

Estonia NICU Care Model Parents are Primary Care-Givers, not nurses Parents responsible for all care except IV, medication Parents participate in rounds, reports, charting Encourage developmental & kangaroo care Nurses are teachers and consultants Results = 30% reduction in NI 30% improvement in weight gain 20% reduction in LOS 50% reduction in nurse utilization improved parent/staff satisfaction

Current Family Centered Care Baby Nurse Doctor Therapist Family

Family Integrated Care Nurse Therapist Parent Volunteer Doctor

Family Integrated Care Pilot Funded by AHFMR/MOHLTC Formative pilot at Mt Sinai 2011 Eligible patients = CPAP or less support Parents and Providers as planning co-leads Tremendous support from parent volunteers Planning, protocols, training modules, ethics, legal completed 40 families

Family Integrated Care Pilot Results Mount Sinai Hospital, Toronto 25% improvement in weight gain Decreased nosocomial infection - from 11.5% to zero Reduced critical incident reports - from 10% to zero Decreased parental stress CIHR funding for cluster randomized controlled trial at 16 hospitals NCE application for KT to all Level 2 NICUs

NEC Strategies The Japanese Way

NEC Incidence: Canada & Japan

Japan NEC Strategy Exclusive breast milk feeding for <28 weeks Aggressive feeding – full feeds in one week Avoid umbilical catheters Early use of PIC lines to reduce skin breaks Use antibiotics only if evidence of infection Transpyloric feeding catheters Probiotics Glycerin enema Minimal handling Encourage developmental & kangaroo care

Breast Milk for All Babies Winnipeg Montreal Vancouver Halifax Calgary Toronto “Back to Basics – learn to respect Nature”

Health System Implications Parents Provide Care Appropriate use Of technology Milk Bank GentleR FAMILY INTEGRATED CARE Developmental care Improved feeding Enhanced Follow-Up Change in roles Fewer staff Re-train staff Re-develop Facilities Re-organize Perinatal regionalization Improved outcomes Reduced costs

Thank You With acknowledgements: Canadian Neonatal Network Canadian Institutes of Health Research Michael Smith Foundation for Health Research Ontario Ministry of Health & Long Term Care Participating Institutions