| ObjectiveTo investigate the effect of multi-center evidence-based practice for improving quality(EPIQ)program in very low birth weight infants(VLBWIs)in reducing hypothermia and improved complications of premature infants,and then to provide clinical evidence for continuous admission hypothermia quality improvement(QI)in neonatal intensive care units(NICUs).MethodsThis study is a multicenter time-sequence cohort study based on a prospective CARE-Preterm(Chinese Adverse Prognosis of very preterm infants)cohort.The data extracted from Sino-Northern Neonatal Network(SNN)in China.VLBW infants in 14 hospitals were admitted from January 1,2018 to December 31,2021.Two groups were divided to the pre-QI group in 2018,and the post-QI group in 2019-2021 according to the implementation of the EPIQ program(came into practice in January 1,2019).The primary and secondary outcome indicators were compared between two groups.The primary outcome indicators are the incidence of admission hypothermia(<36.5℃)and moderate-to-severe hypothermia(<36.0℃).The secondary outcome indicators are in-hospital mortality and incidence of major adverse complications of VLBWIs.In addition,subgroup analysis was carried out on the post-QI group for 3 years,and process indicators such as temperature distribution,rewarming,and the implementation of thermal insulation measures were analyzed in 3 subgroups.Standard P-control plots in VLBW infants with hypothermia and moderate-to-severe hypothermia was drawn in chronological order.χ2 test,rank-sum test,Bonferroni test and binary logistic regression were used for statistical analysis.Results3012 VLBWIs were included in this study.Seven hundred fifteen neonates in the pre-QI period and 2297 in the post-QI period,respectively.Compared with the pre-QI group,the incidence of hypothermia was significantly decreased in the post-QI group[93.4%(668/715)vs.77.9%(1789/2297),P<0.001].Moderate-to-severe hypothermia decreased significantly in the group after QI[52.4%(375/715)vs.34.2(786/2297),P<0.001].The proportion of normothermia in the post-QI group was significantly higher than that in the pre-QI group[6.6%(47/715)vs.21.9(502/2297),P<0.001].There was no increase in the risk of hyperthermia[0.0%(0/715)vs.0.3%(6/2297),P=0.173).After QI,the hypothermia and moderate-to-severe hypothermia P control graphs showed that the center line decreased by years from 93.4%and 52.5%of baseline to 64.4%and 26.9%in 2021 respectively,decreased by 29%and 25.6%after 3 years.There were no significant differences in demographic data including gestational age(GA),birth weight(BW),sex,multiple births,artificial impregnation,cesarean section,maternal hypertension,gestational diabetes mellitus(GDM),intubation at delivery room,antenatal use of steroid between the two groups before and after QI.Compared with pre-QI group,the adverse outcomes including the in-hospital mortality of the VLBW infants decreased[6.3%(137/2297)and 9.2%(66/715),P=0.007],and the incidence of late onset sepsis(LOS)was significantly decreased[14.3%(328/2297)vs.27.3(195/715),P<0.001].Adjusted for gestational age and weight,in-hospital mortality and the risk of LOS still decreased significantly[aOR(adjusted odd ratios,OR):0.545,95%CI:0.391-0.760;aOR:0.427,95%CI:0.348 to 0.543].There were no significant difference in the main complications include neonatal respiratory distress syndrome(RDS),pulmonary hemorrhage,and bronchopulmonary dysplasia(BPD),patent ductus arteriosus(PDA)which requiring treatment,intraventricular hemorrhage(IVH)(Papile grade≥3),Necrotizing enterocolitis(NEC)(Bell stage≥2),Retinopathy of prematurity(ROP)(stage≥3),adverse outcomes(death and occurrence of any of the following complications:≥3 grade IVH,≥3 stage ROP,Bell stage≥2 NEC and pulmonary hemorrhage).From 2019 to 2021,the proportion of infants whose body temperature reached 36.5℃ within 1 hour after birth increased year by year(40.3%,51.0%,66.0%,P=0.001);Compared with 2019,the implementation rate of overall EPIQ measures increased significantly from 2020 to 2021(67.1%,80.9%,80.1%,χ^2=28.628,P<0.001).The main measures to keep warm included placing a pre-warmed hat(87.5%,91.1%and 92.5%,χ2=7.471,P=0.024),using heat-generating mattress(90.7%,92.0%and 93.1%,χ2=6.054),P=0.048),the use of transport warm incubators(81.2%,89.3%and 91.3%,χ2=12.795,P=0.002),preheating the goods into NICU(69.5%,84.6%and 89.9%,χ2=31.903,P<0.001)and the rate of temperature measurement in delivery room or operating room(84.4%,89.8%and 91.6%,χ2=9.450,P=0.009)increased year by year from 2019 to 2021.Units participating in QI program have different quality improvement effects Comparing the implementation rate of main thermal insulation measures in each unit,it was found that the median of admission hypothermia and moderate-to-severe hypothermia QI degree between units were[M(min～max),12.4%(0.6%～54.2%)]and[10.2%(0%～77.9%)],respectively.The median of main thermal insulation measures also differed from NICUs,such as placing a pre-warmed hat[94.5%(16.4-100%)],wrapping with a polyethylene wrap without drying[97%(32.7-100%)],preheating mattress[97%(27.3-100%)],temperature measurement in operating room[93.9%(14.5-100%)],application of transport warm incubators[93.4%(14.5-100%)]preheating the goods into NICU[86.6%(5.7-100%)],and temperature of retest[95.6%(23.6%～100%)].Correlation analysis showed that there was a significant negative correlation between implementation rate of monthly overall insulation interventions and incidence of admission hypothermia(Spearman correlation coefficient γs=-0.432,P=0.009).Temperature measuring at different times after born increased with the extension of hospital time,and the median of temperature measuring at 10,30,60,90,120,150 min after born were[M(P25～P75),35.6 ℃(35.0 ℃～36.0℃);35.8 ℃(35.2℃～36.2℃);36.2℃(35.7℃～36.5℃);36.5℃(36.0℃～36.8℃);36.8℃(36.3℃～36.9℃);36.8℃(36.5℃～37.0℃)]respectively.The median rewarming time was 73min(45-131min),and the median rewarming rate was 0.9℃/h(0.6℃/h～1.2℃/h).Subgroup analysis of years in post-QI period showed that the temperature of infants at 10 and 30 minutes after birth increased year by year in 2019,2020 and 2021[35.5℃(34.8～35.9℃)vs.35.6℃(35.0～36.0℃)vs.36.0℃(35.7～36.3℃);35.7 ℃(35.2～36.0℃)vs.35.8℃(35.0～36.3 ℃ vs.36.0 ℃(35.2～36.3 ℃),adjusted P<0.001].Compared with 2019,the rewarming time of 2020 and 2021 was reduced(50.0min(40.0～110.0min)vs.80.0min(50.0～140.0min),which was deformed=0.001.60.0min(30.0～100.0min)and 80.0min(50.0～140.0min),adjusted P=0.006)].Compared with 2019,the rewarming rate in 2020 and 2021 shortened significantly[0.9℃/h(0.6-1.2℃/h)vs.1.1℃/h(0.7-1.3 ℃/h),adjusted P=0.001;(0.4～1.2℃,0.7 ℃/h)vs.1.1 ℃/h(0.7～1.3 ℃/h),adjusted p=0.013).Conclusion1.Implementing evidence-based multicenter hypothermia QI can reduce the incidence of admission hypothermia and moderate-to-severe hypothermia of VLBWIs,and reduce the risk of death and LOS.2.The effect of EPIQ for AH is closely related to the implementation rate of major thermal insulation measures.The higher the overall implementation rate of EPIQ measures,the lower the incidence of AH is.The effect of EPIQ for AH in different participating units had significant differences,and unsatisfactory improvement effect of which is related to poor practical implementation of EPIQ measures. |
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