Morbidity-free survival in extremely premature infants after changes of clinical practices according to evidence-based guidelines: a quality improvement uncontrolled before-after study in a neonatal intensive care unit.

Abstract

Four indicators of severe neonatal morbidity (SNM) (intraventricular hemorrhage stages 3-4, retinopathy of prematurity (ROP) stage 3, severe bronchopulmonary dysplasia (BPD), and/or necrotizing enterocolitis) are well-known to be associated with poor infancy outcome after very preterm birth. Practice changes according to recent guidelines were implemented after medical team restructuration. We hypothesized that these changes may have improved overall survival and SNM-free survival in extremely preterm infants (EPI). We conducted a monocentric, retrospective, uncontrolled before-after study at our neonatal intensive care unit including all inborn alive neonates with gestational age less than 28 weeks during two periods (period 1 2016-2017, period 2 2019-2020). We compared the global and SNM-free survival rates before and after changes were implemented. Clinical, ventilatory, and nutritional data were also collected for comparison. We included 163 EPI (76 for period 1, 87 for period 2). Twenty-five patients deceased before home discharge in each group. The median duration of invasive ventilation was shorter during period 2 (4 vs 17 days, p < 0.01). Patients of period 2 had an earlier exclusive enteral nutrition (20 vs 34 days, p < 0.01). The composite endpoint of "death or SNM" was lower during period 2 (40.2% vs 55.3%, p = 0.06). Neonates of period 2 were more frequently free of any SNM indicators (83.9% vs 66.7%, p = 0.03). ROP and nosocomial infections were less frequent during period 2 (3.2% vs 21.7%, p < 0.005 and 37.1% vs 62.7%, p = 0.006; respectively). We also observed lower rates of moderate and severe BPD during period 2.

Conclusion: The evolution of our clinical practices appears to have positive effects on global and SNM-free survival and seems to have reduced the incidence of nosocomial infections.

What is known: • Using global survival and severe neonatal morbidity-free survival rates allows to compare inter- and intra-team critical care practices in neonatal intensive care units. • Major changes in clinical procedures, in accordance to recent guidelines, were implemented after the restructuration of the medical team in 2018, with the expected objective of improving morbidity and mortality of extremely premature infants (EPI) in our unit.

What is new: • After the changes, EPI exhibit a lower composite endpoint of "death or severe neonatal morbidity (SNM)" and were more frequently free of any SNM indicators concomitantly with a shorter median duration of invasive ventilation and parenteral nutrition. • The evolution of local clinical practices may positively impact mortality and morbidity within a few years.