Changing the Paradigm of Neonatal Care Shoo Lee, MBBS, FRCPC, PhD Paediatrician-in-Chief, Mount Sinai Hospital; Professor of Paediatrics, Obstetrics &

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

Victoria

Vancouver

New Westminster

Edmonton

Calgary

Saskatoon

ReginaWinnipeg

Montreal

OttawaKingston

TorontoLondon

Hamilton

Halifax

St John’s

Canadian Neonatal NetworkTM

Quebec City

Sherbrooke

St John

Moncton

Fredericton

Founded 1995

“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

Evidence

FacilitationContext

Organizational cultureIndividual behaviorBarriers to change

LeadershipChange managementFacilitation tools

Published evidenceEvidence reviewsClinical studies/trials

Local dataBest practice examplesPractice guidelines

Process Data

Outcomes Data

THE EPIQ PROJECT - Transforming Care through Clinical & Implementation

Research

• 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

OUTCOMES(3 years)

• Reduce mortality, major morbidity and hospital length of stay in NICU

Reduced Mortality, Morbidity and Hospital Length of Stayin Canadian Neonatal Intensive Care Units

• 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 CanadaPROJECT

6 Lee SK, Canadian Neonatal Network EPIQ Study Group, CMAJ 2009. DOI 10.1503/cmaj.081727

OBJECTIVE

FamilyIntegratedCare

The Estonian Model

Family Integrated Care

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

Caring for Families

Estonia NICU Care Model

Parents are Primary Care-Givers, not nursesParents responsible for all care except IV,

medicationParents participate in rounds, reports, chartingEncourage developmental & kangaroo care Nurses are teachers and consultantsResults = 30% reduction in NI

30% improvement in weight gain20% reduction in LOS50% reduction in nurse utilizationimproved parent/staff satisfaction

Current Family Centered Care

Baby

Nurse

Doctor

Therapist

Family

Family Integrated Care

Nurse

Therapist

Parent Volunteer

Doctor

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

NECStrategies

The Japanese Way

NEC Incidence: Canada & Japan

NEC Incidence (%)0

1

2

3

4

5

6

7

8

CanadaJapan

Japan NEC Strategy

Exclusive breast milk feeding for <28 weeksAggressive feeding – full feeds in one weekAvoid umbilical cathetersEarly use of PIC lines to reduce skin breaksUse antibiotics only if evidence of infectionTranspyloric feeding cathetersProbioticsGlycerin enemaMinimal handlingEncourage developmental & kangaroo care

Hosp A Hosp B0

2

4

6

8

10

12

FormulaBreast Milk

% NEC

Toronto

HalifaxVancouver

WinnipegMontreal

“Back to Basics – learn to respect Nature”

Breast Milk for All Babies

Calgary

Health System Implications

Re-develop Facilities

Reduced costsImproved outcomes

Change in rolesFewer staff

Re-train staff

Parents Provide Care

Re-organizePerinatal regionalization

Appropriate useOf technology

Developmental careImproved feeding

Enhanced Follow-Up

Milk Bank GentleRFAMILY INTEGRATED

CARE

With acknowledgements:Canadian Neonatal NetworkCanadian Institutes of Health ResearchMichael Smith Foundation for Health ResearchOntario Ministry of Health & Long Term CareParticipating Institutions

Thank You