Changing the Paradigm
of Neonatal Care
Shoo Lee, MBBS, FRCPC, PhD
Paediatrician-in-Chief,
Mount Sinai Hospital;
Professor of Paediatrics, Obstetrics & Gynecology,
and Public Health, University of Toronto;
Scientific Director,
Institute of Human Development,
Child & Youth Health,
Canadian Institutes of Health Research
Conflict of Interest
• None to declare
Canadian Neonatal NetworkTM
Founded
1995
Edmonton
Victoria
Vancouver
New Westminster
Quebec City
Saskatoon
Calgary
Regina
Sherbrooke
Montreal
Winnipeg
Ottawa
London
Kingston
Toronto
St John’s
Moncton
Fredericton
St John
Halifax
Hamilton
“Improve care through research”
Neonatal Outcomes 1960-2000
1960-1985
1990-2000
Source: Congress of USA, Office of Tech Assessment, NTIS order #PB88-158902
4
EPIQ Conceptual Model
Published evidence
Evidence reviews
Clinical studies/trials
Local data
Best practice examples
Practice guidelines
Evidence
Process Data
Outcomes Data
Context
Organizational culture
Individual behavior
Barriers to change
Facilitation
Leadership
Change management
Facilitation tools
THE EPIQ PROJECT - Transforming Care
through Clinical & Implementation Research
Reduced Mortality, Morbidity and Hospital Length of Stay
in Canadian Neonatal Intensive Care Units
OBJECTIVE
• Reduce mortality, major morbidity and hospital length of stay in NICU
PROJECT
• Pilot project in 12 sites outlining new practices for care
• National scale-up of the new practices, implemented in 30 hospitals
and 17 universities across Canada
OUTCOMES
(3 years)
•
•
•
•
•
30% decrease in severe eye disease causing blindness
30% decrease in hospital acquired infection
30% decrease in severe intestinal infection with high mortality
2 days average reduction in length of hospital stay
$7-10M annual cost savings
Lee SK, Canadian Neonatal Network EPIQ Study Group, CMAJ 2009. DOI 10.1503/cmaj.081727
Family
Integrated
Care
Family
Integrated
Care
The Estonian Model
Caring for Families
Mothers health and wellbeing
is considered essential to the
baby’s wellbeing:
- midwife
- psychologist
- physician
• Atmosphere of team support;
• Mother and baby are a unit,
• Nurse partners mother in the
baby’s care
Estonia NICU Care Model
 Parents are Primary Care-Givers, not nurses
 Parents responsible for all care except IV,
medication
 Parents participate in rounds, reports, charting
 Encourage developmental & kangaroo care
 Nurses are teachers and consultants
 Results = 30% reduction in NI
30% improvement in weight gain
20% reduction in LOS
50% reduction in nurse utilization
improved parent/staff satisfaction
Current Family Centered Care
Baby
Nurse
Doctor
Family
Therapist
Family Integrated Care
Nurse
Doctor
Therapist
Parent
Volunteer
Family Integrated Care Pilot
•
•
•
•
•
Funded by AHFMR/MOHLTC
Formative pilot at Mt Sinai 2011
Eligible patients = CPAP or less support
Parents and Providers as planning co-leads
Tremendous support from parent
volunteers
• Planning, protocols, training modules,
ethics, legal completed
• 40 families
Family Integrated Care Pilot Results
Mount Sinai Hospital, Toronto
• 25% improvement in weight gain
• Decreased nosocomial infection
- from 11.5% to zero
• Reduced critical incident reports
- from 10% to zero
• Decreased parental stress
• CIHR funding for cluster randomized controlled
trial at 16 hospitals
• NCE application for KT to all Level 2 NICUs
NEC
Strategies
The Japanese Way
NEC Incidence: Canada & Japan
8
7
6
5
Canada
Japan
4
3
2
1
0
NEC Incidence (%)
Japan NEC Strategy
 Exclusive breast milk feeding for <28 weeks
 Aggressive feeding – full feeds in one week
 Avoid12umbilical catheters
% NEC
 Early10use of PIC lines to reduce skin breaks
 Use antibiotics only if evidence of infection
8
 Transpyloric feeding catheters
Formula
6
 Probiotics
Breast Milk
 Glycerin
enema
4
 Minimal handling
2
 Encourage developmental & kangaroo care
0
Hosp A
Hosp B
Breast Milk for All Babies
Winnipeg
Montreal
Vancouver
Calgary
Halifax
Toronto
“Back to Basics – learn to respect Nature”
Health System Implications
Parents
Provide Care
Milk Bank
Developmental care
Improved feeding
Enhanced Follow-Up
Appropriate use
Of technology
FAMILY
INTEGRATED
CARE
Re-develop
Facilities
Improved outcomes
GentleR
Change in roles
Re-organize
Fewer staff
Perinatal regionalization Re-train staff
Reduced costs
Thank You
With
acknowledgements:
Canadian Neonatal Network
Canadian Institutes of Health
Research
Michael Smith Foundation for
Health Research
Ontario Ministry of Health & Long
Term Care
Participating Institutions