Transcript Document

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
1. Objective
 Systematic reviews of evidence
2. Quantitative analysis
 Multi-centre outcomes and practices
 Identifies practices associated with outcome
variation that can be targeted for intervention
3. Utilizes collective multi-disciplinary expertise
 Infection control, quality improvement, etc
Method
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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)
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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)
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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
Group C
EPIC
Non-EPIC
5 NICU
12 NICU
Excluded
1 NICU
Group A
Group B
NI
BPD
NI
BPD
5 NICU
6 NICU
N = 2666
N = 3275
Control
5 NICU
N = 1129
Selected Patient Characteristics
Characteristics
Number
NI
2336
BPD
2316
Control
1129
Mean Gestation (wk)
Mean Birthweight (kg)
Mean SNAP-II
Male sex (%)
28.5
1246
11.2
57.2
28.9
1315
9.8
55.5
28.9
1150
12.6
56.3
Outborn (%)
Cesarean section (%)
Apgar <7 at 5 min (%)
37.5
54.1
20.3
18.0
55.5
19.1
14.9
58.8
44.0
Antenatal steroids (%)
71.1
70.7
90.5
Group A (NI) – Incidence of NI
Theoretical Infection Rate of Infant in NIT Group, NI Study (Monte Carlo Bootstrap,
n=1000)
27.0%
25.0%
24.1%
Percentage of infected baby
23.0%
21.0%
19.5%
19.0%
18.3%
17.1%
17.0%
16.1%
15.9%
16.0%
16.5%
15.0%
13.0%
12.6%
11.0%
9.0%
Baseline
Oct Dec.2003
JanM ar.2004
AprJun.2004
JulSept .2004
Study period
Oct Dec.2004
JanM ar.2005
AprJun.2005
JulSept .2005
Group A (NI) – Incidence of
BPD
Observed Incidence Rate of CLD Baby at Week 36 in NIT Group, CLD Study
48.0%
44.0%
40.0%
Percentage of CLD baby
38.9%
36.0%
32.0%
31.7%
29.3%
28.0%
28.2%
27.3%
25.4%
24.0%
23.8%
24.2%
23.1%
20.0%
16.0%
Baseline
Oct-Dec.2003
Jan-Mar.2004
Apr-Jun.2004
Jul-Sept.2004
Study period
Oct-Dec.2004
Jan-Mar.2005
Apr-Jun.2005
Jul-Sept.2005
Group A (NI) – Duration of
Oxygen Need
Observed Length of Oxygen Support for CLD Baby in NIT Group, CLD Study
12
Mean length of oxygen support (day)
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10
9.2
9
8.91
8.62
8.39
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7.46
7.34
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6.35
6.13
6
6.25
5
4
Baseline
Oct-Dec.2003
Jan-Mar.2004
Apr-Jun.2004
Jul-Sept.2004
Study period
Oct-Dec.2004
Jan-Mar.2005
Apr-Jun.2005
Jul-Sept.2005
Group B (BPD) – Incidence of
BPD
Group B (BPD) – Duration of
Oxygen Need
Group B (BPD) – Incidence of
NI
Theoretical Infection Rate of Infant in CLD Group, NI Study (Monte Carlo Bootstrap,
n=1000)
23.0%
21.0%
Percentage of infected baby
19.9%
19.0%
17.3%
17.0%
16.5%
15.0%
13.8%
13.7%
13.0%
12.7%
12.6%
11.2%
11.0%
10.4%
9.0%
7.0%
Baseline
Oct Dec.2003
JanM ar.2004
AprJun.2004
JulSept .2004
Study period
Oct Dec.2004
JanM ar.2005
AprJun.2005
JulSept .2005
Group C (Controls) – Incidence
of BPD
Observed Incidence Rate of CLD Baby at Week 36 in Control Group, CLD Study
36.0%
Percentage of CLD baby
31.0%
26.0%
24.7%
22.3%
22.6%
23.2%
22.5%
21.0%
18.6%
18.5%
16.0%
14.9%
14.7%
11.0%
6.0%
Baseline
Oct-Dec.2003
Jan-Mar.2004
Apr-Jun.2004
Jul-Sept.2004
Study period
Oct-Dec.2004
Jan-Mar.2005
Apr-Jun.2005
Jul-Sept.2005
Group C (Controls) – Duration of
Oxygen Need
Observed Length of Oxygen Support for CLD Baby in Control Group, CLD Study
22
Mean length of oxygen support 9day)
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18
16
14.64
14
13.73
13.33
12.76
12.58
12
11.88
11.48
10.43
10
8.62
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6
4
Baseline
Oct-Dec.2003
Jan-Mar.2004
Apr-Jun.2004
Jul-Sept.2004
Study period
Oct-Dec.2004
Jan-Mar.2005
Apr-Jun.2005
Jul-Sept.2005
Group C (Controls) – Incidence
of NI
Percentage of NI(ever infected)
control group (Non-EPIC group)
25.0%
20.0%
15.0%
14.5%
12.3%
16.0%
14.0%
13.7%
11.8%
10.0%
5.0%
10.3%
7.2%
6.0%
0.0%
baseline Oct03- Jan04Dec03 Mar04
Apr04- Jul04- Oct04- Jan05- Apr05- Jul05Jun04 Sept04 Dec04 Mar05 Jun05 Sept05
Quarter
Mortality, ROP, IVH
Group A (NI)
Group B (BPD)
Group C (Control)
Baseline
8th
quarter
P
value
Baseline
8th
quarter
P
value
Baseline
8th
quarter
P
value
5.7
5.4
NS
5.0
4.2
NS
6.0
3.3
NS
ROP
>stage 3
9.5
8.5
NS
4.8
5.4
NS
5.1
7.9
NS
IVH
>grade 3
10.3
9.9
NS
7.8
9.6
NS
8.5
14.6
NS
Mortality
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
EPIC Process
EPIC-I
2002-2005
EPIC/PHSI
2006-2009
EPIC-II
2007-2010
NIT reduced by 60%
CLD reduced by 40%
Target multiple outcomes
Target two outcomes
Test generalizeability
Improve upon EPIC-I
Target multiple outcomes
Test generalizeability
Improve upon EPIC/PHSI
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
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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
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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