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Continued improvement in morbidity reduction in extremely premature infants
  1. Joseph Kaempf1,
  2. Mindy Morris2,
  3. Eileen Steffen3,
  4. Lian Wang4,
  5. Michael Dunn5
  1. 1 NICU, Providence St. Vincent Medical Center, Portland, Oregon, USA
  2. 2 EngageGrowThrive, LLC, Huntington Beach, California, USA
  3. 3 St. Barnabas Medical Center, Livingston, New Jersey, USA
  4. 4 Department of Biostatistics, Providence St. Vincent Medical Center, Portland, Oregon, USA
  5. 5 Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
  1. Correspondence to Dr Joseph Kaempf, NICU, Providence St. Vincent Medical Center, Portland, OR 97225, USA; joseph.kaempf{at}


Objective Provide a progress report updating our long-term quality improvement collaboration focused on major morbidity reduction in extremely premature infants 23–27 weeks.

Methods 10 Vermont Oxford Network (VON) neonatal intensive care units (NICUs) (the POD) sustained a structured alliance: (A) face-to-face meetings, site visits and teleconferences, (B) transparent process and outcomes sharing, (C) utilisation of evidence-based potentially better practice toolkits, (D) family integration and (E) benchmarking via a composite mortality–morbidity score (Benefit Metric). Morbidity-specific toolkits were employed variably by each NICU according to local priorities. The eight major VON morbidities and the risk-adjusted Benefit Metric were compared in two epochs 2010–2013 versus 2014–2018.

Results 5888 infants, mean (SD) gestational age 25.8 (1.4) weeks, were tracked. The POD Benefit Metric significantly improved (p=0.03) and remained superior to the aggregate VON both epochs (p<0.001). Four POD morbidities significantly improved through 2018 – chronic lung disease (48%–40%), discharge weight <10th percentile (32%–22%), any late infection (19%–17%) and periventricular leukomalacia (4%–2%). In epoch 2, 34% of survivors had none of the eight major morbidities, while 36% had just one. Mortality did not change.

Conclusions Inter-NICU collaboration, process and outcomes sharing and potentially better practice toolkits sustain improvement in 23–27 week morbidity rates, notably chronic lung disease, extrauterine growth restriction and the lowest zero-or-one major morbidity rate reported by a quality improvement collaboration. Unrevealed biological and cultural variables affect morbidity rates, countless remain unmeasured, thus duplication to other quality improvement groups is challenging. Understanding intensive care as innumerable interactions and constant flux that defy convenient linear constructs is fundamental.

  • neonatology
  • data collection

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  • Original reference Correction to reference #40 (the doi was left out by the editor staff).

    40. Compton-Phillips, A. Spreading at scale: a practical leadership model for change. NEJM Catalyst 2020.

  • Contributors JK prepared the first draft of the manuscript. JK and LW had full access to the data and take responsibility for the integrity of the data and the accuracy of the data analysis. MM, ES and MD reviewed the entire process, participated in data review and manuscript formulation and approved the final version.

  • Funding The manuscript preparation was supported by Women and Children’s Services, Providence Health, Portland, Oregon, USA.

  • Disclaimer The Vermont Oxford Network had no role in the concept, design, analysis or formulation of this research report. The discussion and views belong solely to the coauthors and do not represent the opinions of the Vermont Oxford Network.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The institutional review board at each hospital approved this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Additional data requests are available on reasonable request if approved by the 10 participant hospitals and the Vermont Oxford Network.

  • Citation Correction to reference #40 (the doi was left out by the copy editor staff).

    40. Compton-Phillips, A. Spreading at scale: a practical leadership model for change. NEJM Catalyst 2020.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.