EPIC Evidence-based Practice Identification and Change Past, Present, and Future Shoo K. Lee, MBBS, FRCPC, PhD Director, Canadian Neonatal Network™ Scientific Director, iCARE Professor of Pediatrics, University of Alberta EPIC/PHSI Training Workshop November 9 & 10, 2006 Toronto ON

Presentation Objectives Overview how EPIC evolved Describe the science behind EPIC Describe future EPIC plans

Background Continuous Quality Improvement (CQI) methods have been investigated for reducing bronchopulmonary dysplasia (BPD) and nosocomial infection (NI) in the NICU Limitation - existing CQI techniques employ a subjective, uncritical approach to practice change that may not be evidence based

How did EPIC Evolve? Problems with traditional continuous quality improvement (CQI) approaches Subjective Not always evidence-based Seldom use data from institutions in question Mostly intra-institutional in nature Results are not always generalizeable We developed EPIC to improve upon traditional CQI approaches

EPIC Objectives To develop a new scientific method for QI – EPIC that is: (a) Evidence-based – uses published evidence (b) Objective – uses data from individual hospitals to identify practices for targeted intervention (c) Collaborative – uses a national network to share expertise and experience To test whether EPIC reduces BPD and NI in a cluster randomized controlled trial of Canadian NICUs

The Thee Pillars of EPIC Objective Systematic reviews of evidence Quantitative analysis Multi-centre outcomes and practices Identifies practices associated with outcome variation that can be targeted for intervention Utilizes collective multi-disciplinary expertise Infection control, quality improvement, etc

Method Prospective cluster randomized controlled trial 12 NICUs Randomization – 6 BPD, 6 NI Each group Control for other Additional controls - 5 other NICUs in CNN that were not participating in the study All infants < 32 weeks gestation were enrolled Definition: (a) BPD – O2 need at 36 weeks GA (b) NI – Positive Blood, CSF or Urine culture 2 phases (a) Baseline period (1 year) (b) Intervention period (2 years) Funded by Canadian Institutes of Health Research

EPIC - Baseline Period (Year 1) Baseline data collection on outcomes and practices Train multi-disciplinary hospital teams Review of published literature Meeting to share findings Identify Critical Care Pathways Qualitative research – identify barriers to change Data analysis – identify practice differences associated with outcome variation for targeted intervention

Data Analysis to Identify Practices for Targeted Intervention Grouped Data Analysis - compare outcome variations among NICUs - identify non-therapy and therapy related risk factors - estimate the attributable risk of risk factors Individual Hospital Data Analysis - calculate hospital specific incidence rates - identify hospital specific risk factors for targeted intervention - conduct trend analysis using control charts Generalized linear mixed effects model - to adjust results for the cluster randomized design Monte Carlo Bootstrap Simulation - to estimate the 95% confidence limits for control charts

Therapy Related Risk Factor for NI - PICC Therapy related risks - central lines, - mechanical ventilation, - parenteral nutrition, - lack of enteral feeding 40% of nosocomial infection associated with central lines PICC lines carried highest risk

Adjusted probability for developing nosocomial infection for PICC lines Line type Risk-Ratio for NI Umbilical catheters 2.0 Broviac cathethers 3.1 PICC catheters 3.5

EPIC – Intervention Period (2 Years) Develop practice change strategies Prepare supporting materials NICU staff communication and training Implement practice change strategies Quarterly change cycles Control Chart feedback Revise strategies, reinforce change

Results EPIC NI BPD NI BPD N = 2666 N = 3275 N = 1129 12 NICU Non-EPIC Group C Non-EPIC 5 NICU Group A NI Group B BPD Control 5 NICU Excluded 1 NICU NI 5 NICU BPD 6 NICU N = 2666 N = 3275 N = 1129

Selected Patient Characteristics NI BPD Control Number 2336 2316 1129 Mean Gestation (wk) 28.5 28.9 Mean Birthweight (kg) 1246 1315 1150 Mean SNAP-II 11.2 9.8 12.6 Male sex (%) 57.2 55.5 56.3 Outborn (%) 37.5 18.0 14.9 Cesarean section (%) 54.1 58.8 Apgar <7 at 5 min (%) 20.3 19.1 44.0 Antenatal steroids (%) 71.1 70.7 90.5

Group A (NI) – Incidence of NI

Group A (NI) – Incidence of BPD

Group A (NI) – Duration of Oxygen Need

Group B (BPD) – Incidence of BPD

Group B (BPD) – Duration of Oxygen Need

Group B (BPD) – Incidence of NI

Group C (Controls) – Incidence of BPD

Group C (Controls) – Duration of Oxygen Need

Group C (Controls) – Incidence of NI

Mortality, ROP, IVH Group A (NI) Group B (BPD) Group C (Control) Baseline 8th quarter P value Mortality 5.7 5.4 NS 5.0 4.2 6.0 3.3 ROP >stage 3 9.5 8.5 4.8 5.1 7.9 IVH >grade 3 10.3 9.9 7.8 9.6 14.6

Conclusions EPIC is effective at reducing NI and BPD in the NICU Interventions targeting one outcome may affect other outcomes EPIC may be more effective and less costly at improving quality of care than traditional CQI methods

EPIC Research Program

Improvements in EPIC/PHSI Eliminate feedback delays one button reports short term feedback & unverified data Decrease onus of data collection Use only relevant CNN data Facilitate communication Knowledge Broker Divide NICUs into 4 groups for quarterly teleconferences, site visits, mentorship Ease implementation 4 groups will have mix of experienced EPIC sites

EPIC/PHSI Plan Make what we learned in EPIC-I available to all Canadian NICUs in EPIC/PHSI Training of Infection Teams – MD, RN, QI Introduce the EPIC interventions-best practice template Review EPIC-I literature reviews Review qualitative findings from EPIC-I Barriers and facilitators to change Develop change strategies for each NICU Implementation of EPIC interventions

Acknowledgements to CIHR, Micheal Smith Foundation, & Canadian Neonatal NetworkTM EPIC Investigators Khalid Aziz, Memorial U Ross Baker, U of Toronto Keith Barrington, McGill U Catherine Cronin, U Manitoba Jill Hoube, UBC Andrew James, U Toronto Joanne Langley, Dalhousie David SC Lee, UWO Shoo K Lee, U Alberta Robert Liston, UBC Ying MacNab, UBC Claudio Martin, UWO Derek Matthew, Victoria Gen H Jochen Moehr, U Victoria Arne Ohlsson, U Toronto Abraham Peliowski, U Alberta Robert Platt, McGill U K. Sankaran, U Saskatchewan Mary Seshia, U Manitoba Nalini Singhal, U Calgary Bonnie Stevens, U Toronto Anne Synnes, UBC Paul Thiesen, BC Children’s H Peter Von Dadelszen, UBC Robin Walker, U Ottawa Elizabeth Whynot, BC Women’s Robin Whyte, Dalhousie U John Zupancic, Harvard U