Association of practice changes with neonatal outcomes, according to reported practice changes
| Practice changes grouped by outcome | Practice change implemented | Cumulative pre-implementation | Cumulative post-implementation | Outcome rate pre-implementation* | Outcome rate post-implementation* | Absolute change in risk (95% CI) | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of sites | No. of infants | Time, mo | No. of infants | Time, mo | No. of infants | % | n/N | % | n/N | ||
| Bronchopulmonary dysplasia | |||||||||||
| Use of T-piece resuscitator | 7 | 2386 | 191 | 1279 | 149 | 1107 | 46.4 (43.3 to 49.3) | 501/ 1081 | 46.1 (42.8 to 49.4) | 414/ 898 | −0.2 (−4.6 to 4.2) |
| Enhancing or ensuring early CPAP use | 5 | 1405 | 167 | 1129 | 76 | 276 | 44.4 (41.2 to 47.6) | 420/947 | 43.0 (36.6 to 49.4) | 98/228 | −1.4 (−8.6 to 5.8) |
| Controlled oxygen use/review oxygen saturation | 5 | 1437 | 137 | 946 | 106 | 491 | 35.9 (32.6 to 39.2) | 289/806 | 31.7 (27.2 to 36.2) | 131/413 | −4.2 (−9.8 to 1.4) |
| Early surfactant and/or early extubation | 5 | 820 | 101 | 406 | 142 | 414 | 55.1 (49.8 to 60.6) | 182/330 | 37.6 (32.5 to 42.7) | 130/346 | −17.7 (−25.0 to −10.2) |
| Ventilator weaning algorithm | 3 | 669 | 44 | 181 | 102 | 488 | 52.2 (44.4 to 60.2) | 81/155 | 55.4 (50.6 to 60.0) | 238/430 | 3.1 (−6.2 to 12.2) |
| Prophylactic surfactant | 1 | 23 | 12 | 11 | 37 | 12 | 25.0 (0.0 to 55.0) | 2/8 | 36.4 (8.0 to 64.8) | 4/11 | 11.4 (−29.9 to 52.7) |
| Severe neurologic injury | |||||||||||
| Delayed cord clamping | 7 | 1260 | 190 | 739 | 150 | 521 | 19.1 (16.1 to 22.1) | 130/682 | 25.6 (21.8 to 29.4) | 127/496 | 6.5 (1.7 to 11.3) |
| Use of antenatal MgSO4 | 4 | 902 | 129 | 545 | 65 | 357 | 20.4 (16.8 to 24.0) | 100/491 | 22.4 (17.9 to 26.9) | 73/326 | 2.0 (−3.8 to 7.8) |
| Minimal use of volume expanders | 1 | 130 | 16 | 46 | 33 | 84 | 25.0 (11.6 to 38.4) | 10/40 | 10.7 (3.7 to 17.7) | 8/75 | −14.3 (−29.4 to −0.8) |
| Minimal use of inotropes | 1 | 130 | 12 | 32 | 37 | 98 | 35.7 (18.0 to 53.4) | 10/28 | 9.2 (3.1 to 15.3) | 8/87 | −26.5 (−45.3 to −7.7) |
| Severe retinopathy of prematurity | |||||||||||
| Controlled oxygen use | 11 | 2780 | 309 | 1783 | 225 | 997 | 15.1 (13.1 to 17.1) | 183/1213 | 14.2 (11.6 to 16.8) | 97/681 | −0.9 (−4.2 to 2.4) |
| Improved screening protocol | 1 | 46 | 40 | 32 | 9 | 14 | 23.8 (5.6 to 42.0) | 5/21 | 0 | 0/7 | −23.8 (−42.0 to −5.6) |
| Necrotizing enterocolitis | |||||||||||
| Feeding guidelines | 11 | 2692 | 292 | 1372 | 242 | 1320 | 10.0 (8.4 to 11.6) | 135/1351 | 7.9 (6.4 to 9.4) | 104/1320 | −2.1 (−4.3 to 0.1) |
| Early feeding | 5 | 1353 | 110 | 739 | 133 | 614 | 6.1 (4.4 to 7.8) | 45/734 | 8.8 (6.6 to 11.0) | 54/613 | 2.7 (−0.001 to 5.5) |
| Use of donor milk | 4 | 971 | 85 | 645 | 61 | 326 | 11.0 (8.6 to 13.4) | 70/634 | 8.9 (5.8 to 12.0) | 29/325 | −2.1 (−6.0 to 1.8) |
| Colostrum/enhanced expressed breast milk | 3 | 1140 | 56 | 355 | 90 | 785 | 10.2 (7.0 to 13.4) | 35/344 | 4.8 (3.3 to 6.3) | 38/785 | −5.3 (−8.9 to −1.9) |
| Early total parenteral nutrition | 2 | 115 | 52 | 66 | 45 | 49 | 1.5 (0.0 to 4.5) | 1/65 | 4.1 (0.0 to 9.7) | 2/49 | 2.5 (−3.7 to 8.9) |
| Hold enteral feeds during erythrocyte transfusions | 2 | 297 | 70 | 218 | 27 | 79 | 11.1 (6.9 to 15.3) | 24/217 | 5.1 (0.2 to 10.0) | 4/79 | −6.0 (−12.4 to 0.4) |
| Nosocomial infection | |||||||||||
| Central line management, bundle | 13 | 3859 | 327 | 2110 | 304 | 1749 | 31.8 (29.8 to 33.8) | 670/2110 | 26.1 (24.0 to 28.2) | 457/1749 | −5.7 (−8.6 to −2.8) |
| Hand hygiene | 10 | 2350 | 213 | 963 | 272 | 1387 | 32.1 (29.2 to 35.0) | 309/963 | 30.4 (28.0 to 32.8) | 421/1381 | −1.7 (−5.5 to 2.1) |
| Central line management, single intervention | 9 | 2294 | 284 | 1493 | 153 | 801 | 31.4 (28.9 to 33.7) | 468/1493 | 22.1 (19.2 to 25.0) | 177/801 | −9.3 (−12.9 to −5.5) |
| Education, audit, team-building | 6 | 1505 | 109 | 448 | 183 | 1057 | 31.9 (27.6 to 36.2) | 143/448 | 30.6 (27.8 to 33.4) | 323/1057 | −1.3 (−6.4 to 3.8) |
| Reduce skin breaks | 5 | 802 | 126 | 372 | 117 | 430 | 31.5 (26.8 to 36.2) | 117/372 | 35.8 (31.3 to 40.3) | 154/430 | 4.4 (−2.2 to 10.8) |
| Skin-to-skin care | 4 | 1231 | 87 | 505 | 108 | 726 | 32.3 (28.2 to 36.4) | 163/505 | 28.1 (24.8 to 31.4) | 204/726 | −4.2 (−9.4 to 1.0) |
| Checklist for central lines | 3 | 436 | 81 | 237 | 65 | 199 | 29.1 (23.3 to 34.9) | 69/237 | 27.6 (21.4 to 33.8) | 55/199 | −1.5 (−10.0 to 7.0) |
Note: CI = confidence interval, CPAP = continuous positive airway pressure, MgSO4 = magnesium sulphate.
↵* Outcome rates (and 95% CIs) were calculated according to the date of implementation of the specific change at sites that reported implementing that change, where “pre-implementation” is the period before the date of implementation and “post-implementation” is the period after the date of implementation (within the study period), based on n/N, where n = number of infants with the outcome and N = number of infants with data available for that outcome.