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Rapporteur report

Dr Shoo K. Lee

30 January 2017

An EPIQ success – changing our views on healthcare delivery research in neonatal intensive care

Watch Professor Lee's presentation on You Tube at the link below

Quick summary:

  • Reconfiguring healthcare delivery can improve outcomes without the need for new technology 
  • Combining scientific (evidence) and business (quality and implementation) approaches has improved neonatal intensive care outcomes in Canada and internationally
  • Involving parents in the care of their babies in intensive care improves outcomes. 

We can do better in healthcare with what we already have if we look at things differently and reconfigure.   That was a strong message from an inspiring talk by neonatologist and health economist Dr Shoo K. Lee at the HRB 30 Conference in Dublin Castle, where he described how combining approaches from science and business and by challenging ingrained cultural assumptions, Canada has blazed a trail of studies to improve outcomes for the most vulnerable of patients: babies in neonatal intensive care units, or NICUs. 

Dr Lee, who is Professor of Paediatrics, Obstetrics & Gynaecology and Public Health at the University of Toronto and Director of the Maternal-Infant Care Research Centre at Mt. Sinai Hospital, spoke about how the scientific approach of a randomised controlled trial (RCT), which compares treatment A and treatment B, is good for single interventions.

Meanwhile a ‘continuous quality improvement’ or CQI approach is used in business to change behaviour and culture. 

But how about combining the scientific rigour of RCTs with the implementation strengths of CQI? That, it turns out, is a winning formula for the complex setting of neonatal intensive care. 

Focus on implementation and outcomes 

Dr Lee and colleagues started linking together a network of NICUs in Canada in the mid-1990s and developed a process called EPIQEvidence-based Practice for Improving Quality - that collected and compared data not only on outcomes but also on processes, and sought to figure out why individual hospitals were doing well or not well. 

With a focus on implementation, they sent teams to hospitals to recommend changes that might be needed before embarking EPIQ studies on infection and lung problems. ‘Very often people know what they have to do but it is hard to implement changes’, explained Dr Lee, who is Scientific Director of Human Development, Child and Youth Health at the Canadian Institutes of Health Research. 

Then by running trials with the environment and behaviours in mind, EPIQ was able to identify more nuanced factors in improving patient outcome. 

One study on changing the insertion of central lines initially reduced infection rates, but then infections increased, suggesting problems around line maintenance. ‘We went to hospitals to talk to them’, recalled Dr Lee. ‘They realised they had infection problem, they had introduced line protocols but they were not addressing the whole range of things that were problems for infection, such as skin care’. 

Doing better with what we already know 

The EPIQ-II study went on to target multiple outcomes, recruiting international hospitals and learning from best practice and a network of EPIQ NICUs now circles the world. 

Looking across a decade of EPIQ activity for babies less than 32 weeks of gestation, Dr Lee noted figures of a third decrease in adverse outcomes, including reductions in eye disease, infections and lung disease. ‘That is a huge improvement… a big deal’, he said. ‘And this is without using any new tech or knowledge, this is simply doing better with what we already know, that is the lesson’. 

Parent and patient power 

One of the most striking changes in thinking for the Canadian NICU system was to involve parents more in the care of their babies in NICU. Dr Lee spoke about how on a visit to Estonia he learned how a shortage of nursing staff had meant that parents learned from nurses about how to contribute to the care of their babies, such as managing the charts. 

Dr Lee and colleagues met with initial reluctance from healthcare staff in Canada but piloted a scheme there to train and engage parents in the care of their own babies in NICU. ‘Nurses are teachers and consultants and parents are caregivers’, explained Dr Lee, who was both surprised and delighted to see such high numbers of parents willing to play an active role, learning practical skills to care for their premature babies. ‘By the end of the study after a year, most nurses said it was right, we had changed the culture’. 

The study ramped up to a 26-centre international trial, and Dr Lee noted that a the soon-to-be-published results show increased weight gain in babies, increased breastfeeding rates and reductions in medication error. 

‘We probably got it wrong in modern healthcare, because we thought that healthcare has to be delivered by professionals to patients, but we need to make [patients] an active part of the care process itself’, he said. ‘If we change this paradigm of thinking, this process can probably be applied to many other areas of healthcare’.

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