Evidence-based Practice For Improving Quality Research Articles

36 Quality Improvement Integrated Kangaroo Mother Care (QIiKMC)-Development with Evidence-based Practice for Improving Quality (EPIQ) to Improve Learning and Implementation

Abstract Introduction/Background Kangaroo Mother Care (KMC) improves outcome for small newborns, but implementation has been slow. This lag may be associated with lack of short, effective learning programs for healthcare workers, and limited ability to overcome barriers to KMC program development. Objectives To develop a practical learning program for KMC with focus on facilitating healthcare workers assisting the learning of mothers and other family members in KMC care of small babies. To integrate KMC with quality improvement to assist healthcare workers overcome barriers to implementation and improve practice. Design/Methods Six neonatologists, with other global experts, developed as simulation-based, interactive, 12-contact-hour learning program with virtual pilot testing in Uganda, Tanzania, and Nepal, prior to implementation in Mbarara Regional Referral Hospital in Uganda. Revisions in QIiKMC course content and integration with quality improvement were accompanied by development of A KMC Readiness, Survey, Knowledge and Confidence Check, Parent Information, and Course Evaluation, with all components available at www.cnf-fnc.ca. Results Thirty-three nurses and physicians increased knowledge scores from 79% to 88% post-learning. 77% indicated the course was useful or very useful, appreciating “The link between EPIQ and KMC in identification and solving problems” and the “Usefulness of family involvement in caring for the newborn in the hospital and home”. Participants indicated preferences for face-to-face learning and more time for hands-on practice. KMC for small babies increased from 0% to 65% (by August-October 2022). Length of hospital stay decreased by 5 days. Government increased KMC beds from 4 to 8. Staff reported increased job satisfaction along with increased quality improvement activities. Family members in addition to mothers were involved (especially with multiple births or if the mother was ill). Families helped other families with learning. One father reported that “When my baby grows up, I will let him know that it was my warmth which kept him alive”. Conclusion Development of a short, practical KMC learning program was feasible. Integration with quality improvement was empowering and impactful. Acknowledgements Funding from the Royal College of Physicians and Surgeons of Canada and a Rotary Global Grant is appreciated. Potential competing interests Funding for learning program development was received from the Royal College of Physicians and Surgeons of Canada. Funding for KMC implementation in Uganda was supported by a Rotary Global Grant.

Teaching quality improvement concepts to pharmacy students using the Evidence-based Practice for Improving Quality (EPIQ) workshop

Background and purposeDespite the benefits of quality improvement (QI) training, there is a scarcity of information on QI teaching formats for undergraduate pharmacy education. The Evidence-based Practice for Improving Quality (EPIQ) workshop was evaluated as a teaching format for a group of multi-year undergraduate pharmacy students, assessing knowledge acquisition and learner reactions. Educational activity and settingUsing a convergent mixed-method analysis, 10-item pre- and post-workshop multiple-choice questionnaires measured students' knowledge acquisition of foundational QI concepts. A six-item pre- and post-workshop survey and a voluntary post-workshop focus group evaluated students' attitudes towards QI training and the teaching format. Mann-Whitney U non-parametric test was used to analyze the quantitative data, while thematic analysis was applied to analyze the qualitative data. FindingsTwenty-nine pharmacy students participated in the workshop. There was a statistically significant improvement in pharmacy students’ QI knowledge before and after participating in the workshop (77% vs. 86%, P = .008). The evaluation of the EPIQ teaching format resulted in three important findings: (1) undergraduate pharmacy students identified a QI learning need; (2) the EPIQ workshop effectively provided foundational QI literacy for all pharmacy student years using a “learning by sharing” methodology and pharmacy-specific case studies; and (3) interested students may benefit from an experiential elective to apply QI techniques. SummaryThe perceived value of QI training for pharmacy students using the EPIQ workshop was demonstrated: students expressed an interest in lifelong learning and a desire to pursue QI projects at school, during a clinical rotation, or at work.

A survey of minimally invasive surfactant therapy in Canada

IntroductionMinimally invasive surfactant therapy (MIST) can be used to treat neonatal respiratory distress syndrome in neonatal intensive care units (NICUs). Clinical and institutional variances in MIST utilization persist globally with little published research regarding MIST utilization in Canada. Therefore, the objective of this study was to survey MIST utilization in NICUs in Canada.MethodsAn online survey was emailed to the 33 participating centres of Canadian Neonatal NetworkTM (CNN) Evidence-based Practice for Improving Quality (EPIQ) Lung Health Group (LHG). Site demographics and surfactant therapy procedural details were categorically collected. Free text and multiple-choice questions were utilized to capture perceived barriers and individual preferences for MIST use.ResultsTwenty-eight of 33 participating members of the CNN EPIQ-LHG completed the survey between April 2021 and October 2021 (85%); 17/28 (61%) respondents reported ongoing MIST utilization at their center. Most centers that used MIST techniques administered bovine lipid extract surfactant (68%), commonly using angiocatheters (47%) and purpose-built catheters (41%). MIST was widely used for patients at 26–33 weeks gestational age (88%). Nine centres had never used MIST (32%), and 3 indicated a plan to implement MIST within the next 2 years. Common barriers to MIST use included lack of consensus amongst clinicians (78%), lack of training (56%), and lack of experience with MIST (56%).ConclusionWhile MIST is being increasingly used in Canadian NICUs, universal use is yet to be seen. Clinician inexperience and lack of consensus, formal training, and local guidelines contribute to underutilization of MIST. Training workshops, country-wide data collection, and uniform operating protocols are needed to standardize practice.

Applying improvement science to establish a resident sustained quality improvement (QI) educational model

BackgroundPrior to 2017, internal medicine (IM) residents at the University of Alberta did not have a standardised quality improvement (QI) educational curriculum. Our goal was to use QI principles to...

Introducing evidence-based practice improvement in Chinese neonatal intensive care units.

China has the largest population in the world. With rapid economic growth, the incidence of premature birth has shown an increasing trend and more neonatal intensive care units (NICUs) are being established across the country. However, there is substantial variability in clinical practice and variations in short- and long-term outcomes among patients in different NICUs. There remains a big gap between China and developed countries in terms of infant outcomes. The Evidence-based Practice for Improving Quality (EPIQ) is a successful model that has been implemented in NICUs across Canada to improve infant outcomes. We applied EPIQ in a single NICU in china and successfully reduced the incidence of ventilator-associated pneumonia, central line (CL) associated bloodstream infection (CLABSIs), and improved the breastmilk use in NICU. In the next phase, we are extending EPIQ to another 24 centers in China and have established the Chinese Neonatal Network for national collaboration, to improve infant outcomes across China.

Application of the Evidence-based Practice for Improving Quality method in neonatal intensive care units

The Evidence-based Practice for Improving Quality (EPIQ) method was proposed by Canadian Neonatal Network for high quality health care. The method is characterized by evidence-based, targeted, collaborative and continuous concept. At present it is applied in neonatal intensive care units (NICUs). This review article focuses on the application of the method in NICUs.

TEN EPIQ STEPS TO IMPROVING CARE AND OUTCOMES IN RURAL TANZANIA

Abstract BACKGROUND Maternal and child health (MCH) remains a priority globally and in Mwanza Region, Tanzania, where under-five mortality exceeds 100/1000 live births. Facility-based Quality Improvement (QI) is critical to enhancing MCH service delivery. The ‘Evidence-based Practice for Improving Quality (EPIQ)’ approach aims to equip clinical providers with basic QI understanding and skills. In Canada, EPIQ introduction has led to significant newborn intensive care improvements. OBJECTIVES To adapt, pilot and evaluate an EPIQ workshop for rural Tanzania. DESIGN/METHODS The 10-step EPIQ process is introduced through a practical, clinically-focused, hands-on workshop. A team of Canadian EPIQ experts with African partnership experience initially adjusted the EPIQ package for a Tanzanian pilot. They then facilitated a one day EPIQ training-of-trainers to QI-interested Tanzanian university faculty and health managers. The new facilitators then delivered the training to selected local health providers. The EPIQ training was evaluated through facilitator and provider (1) pre/post QI-focused knowledge tests, (2) pre/post QI confidence surveys and (3) post-workshop satisfaction surveys. Post training semi-structured group interviews also collected feedback on workshop content and format from facilitators. Written surveys and tests were analyzed using descriptive statistics and aggregate scores; semi-structured interview notes were reviewed for key themes, recommendations and representative quotations. RESULTS Workshop content including flipcharts, workbooks and locally-relevant cases were prepared. In September 2017, workshops were delivered to 16 facilitators and 29 providers in Mwanza. Post-workshop, overall knowledge scores increased by +7.6% (facilitators) and +2.1% (providers). Aggregate confidence survey scores (5-point Likert) increased for both groups by a median increase of 1 (20%). Participant workshop satisfaction scores averaged 4.7/5. Interviews suggested indicated content was perceived as very relevant however too heavy for allocated time; certain wording was too complex for the language setting. Participants reported that the small group and hands-on format encouraged skill development and EPIQ tools equipped for critical thinking and problem solving. It was strongly recommended to increase workshop length to two days. CONCLUSION A clinically-focused, participatory EPIQ training was feasible and well-received in this setting. Despite self-reported confidence increase, a lacking associated knowledge increase may reflect content too complex, limited workshop duration or poor knowledge test face validity. Future considerations should include revised content and/or knowledge testing tool, extended length, and post-workshop implementation follow-up.

The role of organizational context in moderating the effect of research use on pain outcomes in hospitalized children: a cross sectional study

BackgroundDespite substantial research on pediatric pain assessment and management, health care professionals do not adequately incorporate this knowledge into clinical practice. Organizational context (work environment) is a significant factor in influencing outcomes; however, the nature of the mechanisms are relatively unknown. The objective of this study was to assess how organizational context moderates the effect of research use and pain outcomes in hospitalized children.MethodsA cross-sectional survey was undertaken with 779 nurses in 32 patient care units in 8 Canadian pediatric hospitals, following implementation of a multifaceted knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ). The influence of organizational context was assessed in relation to pain process (assessment and management) and clinical (pain intensity) outcomes. Organizational context was measured using the Alberta Context Tool that includes: leadership, culture, evaluation, social capital, informal interactions, formal interactions, structural and electronic resources, and organizational slack (staff, space, and time). Marginal modeling estimated the effects of instrumental research use (direct use of research knowledge) and conceptual research use (indirect use of research knowledge) on pain outcomes while examining the effects of context.ResultsSix of the 10 organizational context factors (culture, social capital, informal interactions, resources, and organizational slack [space and time]) significantly moderated the effect of instrumental research use on pain assessment; four factors (culture, social capital, resources and organizational slack time) moderated the effect of conceptual research use and pain assessment. Only two factors (evaluation and formal interactions) moderated the effect of instrumental research use on pain management. All organizational factors except slack space significantly moderated the effect of instrumental research use on pain intensity; informal interactions and organizational slack space moderated the effect of conceptual research use and pain intensity.ConclusionsMany aspects of organizational context consistently moderated the effects of instrumental research use on pain assessment and pain intensity, while only a few influenced conceptual use of research on pain outcomes. Organizational context factors did not generally influence the effect of research use on pain management. Further research is required to further explore the relationships between organizational context and pain management outcomes.

The Canadian Pediatric Surgery Network Congenital Diaphragmatic Hernia Evidence Review Project: Developing national guidelines for care.

The Canadian Pediatric Surgery Network (CAPSNet) has been collecting population-based data regarding congenital diaphragmatic hernia (CDH) across its 17 perinatal sites since 2005. With >500 infants registered to date, CAPSNet has addressed many critical knowledge gaps pertaining to CDH care. Most importantly, it has identified variability in both CDH practice and outcome across Canada. Using the successful Evidence-based Practice for Improving Quality (EPIQ) method, CAPSNet is undertaking a national, multidisciplinary effort to standardize best practices for CDH, from prenatal diagnosis to hospital discharge, based on the best available evidence. The present article outlines the value of clinical research networks and the process CAPSNet will undertake to produce national consensus guidelines for CDH care.

95: Golden Hour Management Practices for Infants <32 Wks Gestational Age in Canada

Care practices during neonatal transition can significantly impact both short- and long-term neonatal outcomes. The Evidence-based Practice for Improving Quality (EPIQ) II study was initiated in 2009 with the goal of improving neonatal outcomes (results in CMAJ 2014, 186:E485–94). As part of the study, the EPIQ Golden Hour Committee focused on transitional care (TC) practices in the first hour after birth, including use of the 2010 NRP recommendations for immediate management of preterm infants. Determine the current management practices during the Golden Hour for infants of <32 weeks GA in Canadian NICUs. A survey was emailed to all EPIQ II site investigators and/or co-ordinators in August 2014 with two monthly reminders. The survey included questions on unit characteristics, antenatal management, composition of the TC team, and management in the first hour after birth. The responses to the questions were categorized into four GA groups: 230/7–236/7 wks, 240/7–256/7 wks, 260/7–276/7 wks, and 280/7–316/7 wks. Of the 23 EPIQ II NICUs that were perinatal centers, 13 (56%) completed the survey. Eight sites had >15 level III NICU beds. Antenatal counseling was provided >75% of the time by 92% and 77% of units for GA <28 and 28 to 316/7 wks, respectively. A neonatal fellow or neonatologist/paediatrican was mostly responsible for counseling. 92% did not have a structured template for counseling although one-half used decision aids. The TC team consisted of three or more individuals for stabilization of infants of <28 wks GA and neonatologists were present in 92% of the units, this varied according to the time of the day. 77% of units practiced DCC, 100% used thermal wrap to maintain temperature, the initial FiO2 ranged from 21–40%, and 100% followed the NRP recommended oxygen saturation guide. In spontaneously breathing infants, CPAP was the initial mode of ventilatory support. Prophylactic surfactant was administered by 31% of units for <26 wk GA infants. Infants of <24 wks GA were most likely to be intubated and ventilated. Umbilical venous and arterial catheters were used by 92% for infants of 24 wks GA. Most units did not measure sound levels or offer skin-to-skin contact in the delivery room. Most Canadian NICUs practice NRP recommendations for preterm infants. DCC, thermal wrap, non-invasive ventilation, and FiO2 of <40% are used during the first hour after birth.

(455) How long does it last? Sustaining improved pain practices in pediatric hospitals following implementation of a knowledge translation intervention and pain practice booster

Despite substantial pediatric pain research, pain assessment and management practices for hospitalized children remain sub-optimal. To address this research to practice gap, a multidimensional knowledge translation (KT) intervention, Evidence-based Practice for Improving Quality (EPIQ), was implemented. EPIQ significantly improved pain assessment and management from baseline to EPIQ completion; however, the sustainability of these improvements over time and the introduction of a pain practice change booster intervention (Booster) to sustain improved pain practices requires further study.

The Evidence-based Practice for Improving Quality method has greater impact on improvement of outcomes than dissemination of practice change guidelines and quality improvement training in neonatal intensive care units

To determine whether outcome improvements achieved by neonatal intensive care units (NICUs) in the Evidence-based Practice for Improving Quality (EPIQ) trial could be reproduced in other NICUs by providing quality improvement (QI) training and practice change guidelines developed during the EPIQ trial; and to examine whether the results of the EPIQ trial were sustained. The present prospective before-after study included 5812 infants born at ≤32 weeks' gestation and admitted to 19 level 3 NICUs in the Canadian Neonatal Network between October 1, 2005 and December 31, 2007. During a three-month baseline period, multi-disciplinary teams received general training in QI techniques at a two-day workshop, and practice change guidelines targeting nosocomial infection (NI) and bronchopulmonary dysplasia (BPD) developed during the EPIQ trial were provided to all participants. Outcome data collected during the intervention period were compared with data from the baseline period and reported quarterly. In NICUs that had not previously participated in the EPIQ trial (non-EPIQ NICUs), there were no significant changes in the incidence trends of NI or BPD. However, within NICUs that had previously participated in the EPIQ trial (EPIQ NICUs) there was a continued reduction in the incidence trend of NI and BPD among EPIQ NICUs randomized during the trial to reduce NI and BPD, respectively. Providing NICUs with QI training and practice change guidelines developed during a successful QI initiative in other units is not effective. The authors speculate that successful practice change involves organizational culture and behaviour change, and should be driven by context-specific evidence.

Association of a quality improvement program with neonatal outcomes in extremely preterm infants: a prospective cohort study

We previously demonstrated improvement in bronchopulmonary dysplasia and nosocomial infection among preterm infants at 12 neonatal units using the Evidence-based Practice for Improving Quality (EPIQ). In the current study, we assessed the association of Canada-wide implementation of EPIQ with mortality and morbidity among preterm infants less than 29 weeks gestational age. This prospective cohort study included 6026 infants admitted to 25 Canadian units between 2008 and 2012 (baseline year, n = 1422; year 1, n = 1611; year 2, n = 1508; year 3, n = 1485). Following a 1-year baseline period and 6 months of training and planning, EPIQ was implemented over 3 years. Our primary outcome was a composite of neonatal mortality and any of bronchopulmonary dysplasia, severe neurologic injury, severe retinopathy of prematurity, necrotizing enterocolitis and nosocomial infection. We compared outcomes for baseline and year 3 using multivariable analyses. In adjusted analyses comparing baseline with year 3, the composite outcome (70% v. 65%; adjusted odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51 to 0.79), severe retinopathy (17% v. 13%; OR 0.60, 95% CI 0.45 to 0.79), necrotizing enterocolitis (10% v. 8%; OR 0.73, 95% CI 0.52 to 0.98) and nosocomial infections (32% v. 24%; OR 0.63, 95% CI 0.48 to 0.82) were significantly reduced. The composite outcome was lower among infants born at 26 to 28 weeks gestation (62% v. 52%; OR 0.62, 95% CI 0.49 to 0.78) but not among infants born at less than 26 weeks gestational age (90% v. 88%; OR 0.73, 95% CI 0.44 to 1.20). EPIQ methodology was generalizable within Canada and was associated with significantly lower likelihood of the composite outcome, severe retinopathy, necrotizing enterocolitis and nosocomial infections. Infants born at 26 to 28 weeks gestational age benefited the most.

The staying power of change: sustainability of pain practice improvements after a multidimensional knowledge translation intervention

Background Despite significant developments in acute pain research in hospitalized children, pain assessment and management practices for this population remain sub-optimal. To address the gap between research and practice a multidimensional, knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ) [1] was successfully implemented at eight Canadian tertiary pediatric hospitals [2]. EPIQ was effective in improving pain practices immediately following the intervention completion in the EPIQ units compared to standard care (SC) [2]. However, the sustainability of these improvements requires consideration. The objective of this study is to determine the sustainability of the overall effect of EPIQ on pain practices 12 months post intervention.

Analgosedation in neonates: what we know and how we act

Analgosedation in neonates: what we know and how we act Karel Allegaert,1,2 Carlo V Bellieni3 1Department of Development and Regeneration, 2KU Leuven and Neonatal Intensive Care Unit, University Hospitals Leuven, Belgium; 3Department of Pediatrics, Obstetrics and Reproduction Medicine, University of Siena, Siena, Italy Abstract: Inadequate pain management in neonatal life impairs the neurodevelopmental outcome. It alters pain thresholds, pain and stress-related behavior, and physiologic responses in later life. At the same time, there are emerging animal experimental and human epidemiologic data on the impact of analgosedatives on neuroapoptosis and impaired neurodevelopmental outcome. As a consequence, the management of neonatal pain is in search of a new equilibrium since these conflicting (undertreatment versus overtreatment) observations are the main drivers of its current management. Such tailoring includes new treatment modalities, and also more effective implementation strategies. The search for tailored nonpharmacologic (ie, less invasive techniques, preventive strategies, complementary techniques) and pharmacologic (eg, dexmedetomidine, intravenous acetaminophen, remifentanil) treatment modalities are discussed and reflect the increased knowledge on neonatal pain management. Despite this increasing knowledge (&ldquo;toolbox&rdquo;) regarding neonatal pain, there is still a major gap between knowledge (&ldquo;what we know&rdquo;) and practice (&ldquo;how we act&rdquo;). Consequently, more research activity on methods for effective implementation of the available knowledge is needed. Illustrations of effective approaches, eg, the Evidence-Based Practice for Improving Quality (EPIQ) initiative, to bridge this gap are provided. This is followed by an intersubjective proposal on priorities for contemporary clinical management and a research agenda. Keywords: pain, newborn, prevention, guidelines

Pain in hospitalized children: Effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes

Hospitalized children frequently receive inadequate pain assessment and management despite substantial evidence to support effective pediatric pain practices. The objective of this study was to determine the effect of a multidimensional knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ), on procedural pain practices and clinical outcomes for children hospitalized in medical, surgical and critical care units. A prospective cohort study compared 16 interventions using EPIQ and 16 standard care (SC) units in 8 Canadian pediatric hospitals. Chart reviews at baseline (time 1) and intervention completion (time 2) determined the nature and frequency of painful procedures and of pain assessment and pain management practices. Trained pain experts evaluated pain intensity 6months post-intervention (time 3) during routine, scheduled painful procedures. Generalized estimating equation models compared changes in outcomes between EPIQ and SC units over time.EPIQ units used significantly more validated pain assessment tools (P<0.001) and had a greater proportion of patients who received analgesics (P=0.03) and physical pain management strategies (P=0.02). Mean pain intensity scores were significantly lower in the EPIQ group (P=0.03). Comparisons of moderate (4–6/10) and severe (7–10/10) pain, controlling for child and unit level factors, indicated that the odds of having severe pain were 51% less for children in the EPIQ group (adjusted OR: 0.49, 95% CI: 0.26–0.83; P=0.009). EPIQ was effective in improving practice and clinical outcomes for hospitalized children. Additional exploration of the influence of contextual factors on research use in hospital settings is required to explain the variability in pain processes and clinical outcomes.

Mothers' "liquid gold": a quality improvement initiative to support early colostrum delivery via oral immune therapy (OIT) to premature and critically ill newborns.

Early breast milk, known as colostrum ("liquid gold") provides immune benefits to infants, offering potential risk reduction for nosocomial infection (NI) and necrotizing enterocolitis (NEC), a serious gastrointestinal emergency. Provision of colostrum is recognized as oral immune therapy (OIT) and is valuable to all NICU infants unable to feed orally. A quality improvement project was initiated by the multidisciplinary NICU Quality Care Council at London Health Sciences Centres-Victoria (LHSC-VH) to obtain mothers' colostrum for early OIT. The initiative was driven by the Canadian EPIQ (Evidence-based Practice for Improving Quality) group as a means of reducing the rates of NEC and NI, two major morbidities in the NICU. The overall aim was to facilitate the availability of OIT to preterm and critically ill neonates as soon as possible after birth.

What’s Your Literacy Level?

I am writing this editorial after just returning from a conference highlighting an exciting evidence-based project headed by Dr. Shoo Lee from Toronto. Fondly known as EPIQ (Evidence-Based Practice for Improving Quality), this multiyear, multisite study funded by the Canadian Institutes of Health Research uses benchmarking and a process of continuous quality improvement to address five morbidities in low birth weight infants: retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and infection. The three pillars of EPIQ include evaluation and selection of published evidence, identifying hospital-specific practices to target interventions, and building a national body of expertise that can be widely shared among NICUs. Since its inception in 2002, the project has grown to include 27 neonatal units across Canada and has seen the completion of dozens of individual plan-do-study-act cycles.

Reflections on Knowledge Translation in Canadian NICUs Using tahe EPIQ Method

The Canadian Neonatal Network conducted a trial of Evidence-Based Practice for Improving Quality (EPIQ) between 2002 and 2005. Improved neonatal intensive care unit (NICU) outcomes established credibility for quality improvement. We surveyed team members and physician leaders to examine critical success factors and barriers to improvement during EPIQ. Respondents agreed that EPIQ had a high utility, was effectively implemented and was a major learning opportunity. The collaborative nature of the project was key to success. Respondents identified the need for additional training and resources in quality improvement. Better communication between clinicians and senior leaders is required to support quality improvement in NICUs.