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EPIC Evidence-based Practice Identification and Change. Past, Present, and Future Shoo K. Lee, MBBS, FRCPC, PhD Director, Canadian Neonatal Network ™ Scientific Director, iCARE Professor of Pediatrics, University of Alberta EPIC/PHSI Training Workshop November 9 & 10, 2006 Toronto ON.

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epic evidence based practice identification and change
EPIC Evidence-based PracticeIdentification and Change

Past, Present, and Future

Shoo K. Lee, MBBS, FRCPC, PhD

Director, Canadian Neonatal Network™

Scientific Director, iCARE

Professor of Pediatrics, University of Alberta

EPIC/PHSI Training Workshop

November 9 & 10, 2006

Toronto ON

presentation objectives
Presentation Objectives
  • Overview how EPIC evolved
  • Describe the science behind EPIC
  • Describe future EPIC plans
  • Continuous Quality Improvement (CQI) methods have been investigated for reducing bronchopulmonary dysplasia (BPD) and nosocomial infection (NI) in the NICU
  • Limitation - existing CQI techniques employ a subjective, uncritical approach to practice change that may not be evidence based
how did epic evolve
How did EPIC Evolve?
  • Problems with traditional continuous quality improvement (CQI) approaches
    • Subjective
    • Not always evidence-based
    • Seldom use data from institutions in question
    • Mostly intra-institutional in nature
    • Results are not always generalizeable
  • We developed EPIC to improve upon traditional CQI approaches
epic objectives
EPIC Objectives
  • To develop a new scientific method for QI – EPIC

that is:(a) Evidence-based – uses published evidence(b) Objective – uses data from individual hospitals to identify practices for targeted intervention(c) Collaborative – uses a national network to share expertise and experience

  • To test whether EPIC reduces BPD and NI in a cluster randomized controlled trial of Canadian NICUs
the thee pillars of epic
The Thee Pillars of EPIC
  • Objective
    • Systematic reviews of evidence
  • Quantitative analysis
    • Multi-centre outcomes and practices
    • Identifies practices associated with outcome variation that can be targeted for intervention
  • Utilizes collective multi-disciplinary expertise
    • Infection control, quality improvement, etc
  • Prospective cluster randomized controlled trial 12 NICUs
  • Randomization – 6 BPD, 6 NI
  • Each group Control for other
  • Additional controls - 5 other NICUs in CNN that were not participating in the study
  • All infants < 32 weeks gestation were enrolled
  • Definition: (a) BPD – O2 need at 36 weeks GA (b) NI – Positive Blood, CSF or Urine culture
  • 2 phases (a) Baseline period (1 year) (b) Intervention period (2 years)
  • Funded by Canadian Institutes of Health Research
epic baseline period year 1
EPIC - Baseline Period (Year 1)
  • Baseline data collection on outcomes and practices
  • Train multi-disciplinary hospital teams
  • Review of published literature
  • Meeting to share findings
  • Identify Critical Care Pathways
  • Qualitative research – identify barriers to change
  • Data analysis – identify practice differences associated with outcome variation for targeted intervention
data analysis to identify practices for targeted intervention
Data Analysis to Identify Practices for Targeted Intervention
  • Grouped Data Analysis- compare outcome variations among NICUs- identify non-therapy and therapy related risk factors - estimate the attributable risk of risk factors
  • Individual Hospital Data Analysis- calculate hospital specific incidence rates- identify hospital specific risk factors for targeted intervention- conduct trend analysis using control charts
  • Generalized linear mixed effects model- to adjust results for the cluster randomized design
  • Monte Carlo Bootstrap Simulation- to estimate the 95% confidence limits for control charts
therapy related risk factor for ni picc
Therapy Related Risk Factor for NI - PICC
  • Therapy related risks - central lines, - mechanical ventilation, - parenteral nutrition, - lack of enteral feeding
  • 40% of nosocomial infection associated with central lines
  • PICC lines carried highest risk
epic intervention period 2 years
EPIC – Intervention Period (2 Years)
  • Develop practice change strategies
  • Prepare supporting materials
  • NICU staff communication and training
  • Implement practice change strategies
  • Quarterly change cycles
  • Control Chart feedback
  • Revise strategies, reinforce change



Group C



Group A


Group B










N = 2666

N = 3275

N = 1129

  • EPIC is effective at reducing NI and BPD in the NICU
  • Interventions targeting one outcome may affect other outcomes
  • EPIC may be more effective and less costly at improving quality of care than traditional CQI methods
improvements in epic phsi
Improvements in EPIC/PHSI
  • Eliminate feedback delays
    • one button reports
    • short term feedback & unverified data
  • Decrease onus of data collection
    • Use only relevant CNN data
  • Facilitate communication
    • Knowledge Broker
    • Divide NICUs into 4 groups for quarterly teleconferences, site visits, mentorship
  • Ease implementation
    • 4 groups will have mix of experienced EPIC sites
epic phsi plan
  • Make what we learned in EPIC-I available to all Canadian NICUs in EPIC/PHSI
  • Training of Infection Teams – MD, RN, QI
    • Introduce the EPIC interventions-best practice template
  • Review EPIC-I literature reviews
  • Review qualitative findings from EPIC-I
    • Barriers and facilitators to change
  • Develop change strategies for each NICU
    • Implementation of EPIC interventions
acknowledgements to cihr micheal smith foundation canadian neonatal network tm epic investigators
Khalid Aziz, Memorial U

Ross Baker, U of Toronto

Keith Barrington, McGill U

Catherine Cronin, U Manitoba

Jill Hoube, UBC

Andrew James, U Toronto

Joanne Langley, Dalhousie

David SC Lee, UWO

Shoo K Lee, U Alberta

Robert Liston, UBC

Ying MacNab, UBC

Claudio Martin, UWO

Derek Matthew, Victoria Gen H

Jochen Moehr, U Victoria

Arne Ohlsson, U Toronto

Abraham Peliowski, U Alberta

Robert Platt, McGill U

K. Sankaran, U Saskatchewan

Mary Seshia, U Manitoba

Nalini Singhal, U Calgary

Bonnie Stevens, U Toronto

Anne Synnes, UBC

Paul Thiesen, BC Children’s H

Peter Von Dadelszen, UBC

Robin Walker, U Ottawa

Elizabeth Whynot, BC Women’s

Robin Whyte, Dalhousie U

John Zupancic, Harvard U

Acknowledgements to CIHR, Micheal Smith Foundation, & Canadian Neonatal NetworkTM EPIC Investigators