Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative.

Importance: Pediatric ventilator-associated events (PedVAEs, defined as a sustained worsening in oxygenation after a baseline period of stability or improvement) are useful for surveillance of complications from mechanical ventilation. It is unclear whether interventions to mitigate known risk factors can reduce PedVAE rates. Objective: To assess whether adherence to 1 or more test factors in a quality improvement bundle was associated with a reduction in PedVAE rates. Design, Setting, and Participants: This multicenter quality improvement study obtained data from 2017 to 2020 for patients who were mechanically ventilated and cared for in neonatal, pediatric, and cardiac intensive care units (ICUs). These ICUs were located in 95 hospitals participating in the Children's Hospitals' Solutions for Patient Safety (SPS) network in North America. Data analyses were performed between September 2021 and April 2023. Intervention: A quality improvement bundle consisted of 3 test factors: multidisciplinary apparent cause analysis, daily discussion of extubation readiness, and daily discussion of fluid balance goals. This bundle was distributed to a subgroup of hospitals that volunteered to participate in a collaborative PedVAE prevention initiative under the SPS network guidance in July 2018. Main Outcomes and Measures: Each SPS network hospital submitted monthly PedVAE rates from January 1, 2017, to May 31, 2020, and test factor data were submitted from July 1, 2018, to May 31, 2020. Analyses focused on hospitals that reliably submitted PedVAE rate data, defined as outcomes data submission through May 31, 2020, for at least 80% of the baseline and postbaseline periods. Results: Of the 95 hospitals in the SPS network that reported PedVAE data, 21 were grouped in the Pioneer cohort and 74 in the non-Pioneer cohort. Only 12 hospitals (57%) from the 21 Pioneer hospitals and 33 (45%) from the 74 non-Pioneer hospitals were considered to be reliable reporters of outcome data. Among the 12 hospitals, the PedVAE rate decreased from 1.9 to 1.4 events per 1000 ventilator days (absolute rate difference, -0.6; 95% CI, -0.5 to -0.7; P < .001). No significant change in the PedVAE rate was seen among the 33 hospitals that reliably submitted PedVAE rates but did not implement the bundle. Of the 12 hospitals, 3 that reliably performed daily discussion of extubation readiness had a decrease in PedVAE rate from 2.6 to 1.2 events per 1000 ventilator days (absolute rate difference, -1.4; 95% CI, -1.0 to -1.7; P < .001), whereas the other 9 hospitals that did not implement this discussion did not have a decrease. Conclusions and Relevance: This study found that a multicenter quality improvement intervention targeting PedVAE risk factors was associated with a substantial reduction in the rate of PedVAEs in hospital ICUs. The findings suggest that ICU teams seeking to reduce PedVAEs incorporate daily discussion of extubation readiness during morning rounds.

Recruiting Participants for Population Health Intervention Research: Effectiveness and Costs of Recruitment Methods for a Cohort Study.

BACKGROUND: Public health research studies often rely on population-based participation and draw on various recruitment methods to establish samples. Increasingly, researchers are turning to web-based recruitment tools. However, few studies detail traditional and web-based recruitment efforts in terms of costs and potential biases. OBJECTIVE: This study aims to report on and evaluate the cost-effectiveness, time effectiveness, and sociodemographic representation of diverse recruitment methods used to enroll participants in 3 cities of the Interventions, Research, and Action in Cities Team (INTERACT) study, a cohort study conducted in Canadian cities. METHODS: Over 2017 and 2018 in Vancouver, Saskatoon, and Montreal, the INTERACT study used the following recruitment methods: mailed letters, social media (including sponsored Facebook advertisements), news media, partner communications, snowball recruitment, in-person recruitment, and posters. Participation in the study involved answering web-based questionnaires (at minimum), activating a smartphone app to share sensor data, and wearing a device for mobility and physical activity monitoring. We describe sociodemographic characteristics by the recruitment method and analyze performance indicators, including cost, completion rate, and time effectiveness. Effectiveness included calculating cost per completer (ie, a participant who completed at least one questionnaire), the completion rate of a health questionnaire, and the delay between completion of eligibility and health questionnaires. Cost included producing materials (ie, printing costs), transmitting recruitment messages (ie, mailing list rental, postage, and sponsored Facebook posts charges), and staff time. In Montreal, the largest INTERACT sample, we modeled the number of daily recruits through generalized linear models accounting for the distributed lagged effects of recruitment campaigns. RESULTS: Overall, 1791 participants were recruited from 3 cities and completed at least one questionnaire: 318 in Vancouver, 315 in Saskatoon, and 1158 in Montreal. In all cities, most participants chose to participate fully (questionnaires, apps, and devices). The costs associated with a completed participant varied across recruitment methods and by city. Facebook advertisements generated the most recruits (n=687), at a cost of CAD $15.04 (US $11.57; including staff time) per completer. Mailed letters were the costliest, at CAD $108.30 (US $83.3) per completer but served to reach older participants. All methods resulted in a gender imbalance, with women participating more, specifically with social media. Partner newsletters resulted in the participation of younger adults and were cost-efficient (CAD $5.16 [US $3.97] per completer). A generalized linear model for daily Montreal recruitment identified 2-day lag effects on most recruitment methods, except for the snowball campaign (4 days), letters (15 days), and reminder cards (5 days). CONCLUSIONS: This study presents comprehensive data on the costs, effectiveness, and bias of population recruitment in a cohort study in 3 Canadian cities. More comprehensive documentation and reporting of recruitment efforts across studies are needed to improve our capacity to conduct inclusive intervention research.

Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU.

BACKGROUND: Quality improvement (QI) methods have been widely adopted in health care. Although theoretical frameworks and models for organizing successful QI programs have been described, few reports have provided practical examples to link existing QI theory to building a unit-based QI program. The purpose of this report is to describe the authors' experience in building QI infrastructure in a large neonatal ICU (NICU). METHODS: A unit-based QI program was developed with the goal of fostering the growth of high-functioning QI teams. This program was based on six pillars: shared vision for QI, QI team capacity, QI team capability, actionable data for improvement, culture of improvement, and QI team integration with external collaboratives. Multiple interventions were developed, including a QI dashboard to align NICU metrics with unit and hospital quality goals, formal training for QI leaders, QI coaches imbedded in project teams, a day-long QI educational workshop to introduce QI methodology to unit staff, and a secure, Web-based QI data infrastructure. RESULTS: Over a five-year period, this QI infrastructure brought organization and support for individual QI project teams and improved patient outcomes in the unit. Two case studies are presented, describing teams that used support from the QI infrastructure. The Infection Prevention team reduced central line-associated bloodstream infections from 0.89 to 0.36 infections per 1,000 central line-days. The Nutrition team decreased the percentage of very low birth weight infants discharged with weights less than the 10th percentile from 51% to 40%. CONCLUSION: The clinicians provide a pragmatic example of incorporating QI organizational and contextual theory into practice to support the development of high-functioning QI teams and build a unit-based QI program.

INTERACT: A comprehensive approach to assess urban form interventions through natural experiments.

BACKGROUND: Urban form interventions can result in positive and negative impacts on physical activity, social participation, and well-being, and inequities in these outcomes. Natural experiment studies can advance our understanding of causal effects and processes related to urban form interventions. The INTErventions, Research, and Action in Cities Team (INTERACT) is a pan-Canadian collaboration of interdisciplinary scientists, urban planners, and public health decision makers advancing research on the design of healthy and sustainable cities for all. Our objectives are to use natural experiment studies to deliver timely evidence about how urban form interventions influence health, and to develop methods and tools to facilitate such studies going forward. METHODS: INTERACT will evaluate natural experiments in four Canadian cities: the Arbutus Greenway in Vancouver, British Columbia; the All Ages and Abilities Cycling Network in Victoria, BC; a new Bus Rapid Transit system in Saskatoon, Saskatchewan; and components of the Sustainable Development Plan 2016-2020 in Montreal, Quebec, a plan that includes urban form changes initiated by the city and approximately 230 partnering organizations. We will recruit a cohort of between 300 and 3000 adult participants, age 18 or older, in each city and collect data at three time points. Participants will complete health and activity space surveys and provide sensor-based location and physical activity data. We will conduct qualitative interviews with a subsample of participants in each city. Our analysis methods will combine machine learning methods for detecting transportation mode use and physical activity, use temporal Geographic Information Systems to quantify changes to urban intervention exposure, and apply analytic methods for natural experiment studies including interrupted time series analysis. DISCUSSION: INTERACT aims to advance the evidence base on population health intervention research and address challenges related to big data, knowledge mobilization and engagement, ethics, and causality. We will collect ~ 100 TB of sensor data from participants over 5 years. We will address these challenges using interdisciplinary partnerships, training of highly qualified personnel, and modern methodologies for using sensor-based data.