EPIC Evidence-based Practice Identification and Change

1. EPIC Evidence-based PracticeIdentification 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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Adjusted probability for developing nosocomial infection for PICC lines

12. 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

13. Results EPIC 12 NICU 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

14. Selected Patient Characteristics

15. Group A (NI) – Incidence of NI

16. Group A (NI) – Incidence of BPD

17. Group A (NI) – Duration of Oxygen Need

18. Group B (BPD) – Incidence of BPD

19. Group B (BPD) – Duration of Oxygen Need

20. Group B (BPD) – Incidence of NI

21. Group C (Controls) – Incidence of BPD

22. Group C (Controls) – Duration of Oxygen Need

23. Group C (Controls) – Incidence of NI

24. Mortality, ROP, IVH

25. 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

26. EPIC Research Program

27. 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

28. 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

29. 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 Acknowledgements to CIHR, Micheal Smith Foundation, & Canadian Neonatal NetworkTM EPIC Investigators