Background. Medical care for very low birth weight (VLBW) infants and their mothers has changed dramatically during the 1990s, yet it is unclear how these changes have affected mortality and morbidity. Objective. We used the Vermont Oxford Network Database to identify trends in clinical practice and patient outcomes for VLBW infants born from 1991 to 1999. Methods. Logistic regression was used to evaluate temporal trends in practices and outcomes while adjusting for patient characteristics and accounting for clustering of cases within hospitals. Results. There were 118 448 infants 501 to 1500 g from 362 neonatal intensive care units enrolled in the Network Database from 1991 to 1999. Prenatal care, cesarean section, multiple births, antenatal steroids, and 1-minute Apgar scores increased during this period, as did the use of nasal continuous positive airway pressure, high-frequency ventilation, surfactant, and postnatal steroids. The proportion of white infants decreased; the proportions of Hispanic infants and those of other races increased. The crude and adjusted rates of mortality, pneumothorax, intraventricular hemorrhage (IVH), and severe IVH declined from 1991 to 1995, whereas from 1995 to 1999, the rates of mortality, IVH, and severe IVH did not change significantly, and pneumothorax increased. Conclusions. There have been major changes in both obstetric and neonatal care during the 1990s. These changes were associated with decreases in mortality and morbidity for VLBW infants during the first half of the decade. However, since 1995, no additional improvements in mortality or morbidity have been seen, ending a decades-long trend of improving outcomes for these infants.

OBJECTIVE: To identify changes in mortality and neonatal morbidities for infants with birth weight 501 to 1500 g born from 2000 to 2009. METHODS: There were 355 806 infants weighing 501 to 1500 g who were born in 2000–2009. Mortality during initial hospitalization and major neonatal morbidity in survivors (early and late infection, chronic lung disease, necrotizing enterocolitis, severe retinopathy of prematurity, severe intraventricular hemorrhage, and periventricular leukomalacia) were assessed by using data from 669 North American hospitals in the Vermont Oxford Network. RESULTS: From 2000 to 2009, mortality for infants weighing 501 to 1500 g decreased from 14.3% to 12.4% (difference, −1.9%; 95% confidence interval, −2.3% to −1.5%). Major morbidity in survivors decreased from 46.4% to 41.4% (difference, −4.9%; 95% confidence interval, −5.6% to −4.2%). In 2009, mortality ranged from 36.6% for infants 501 to 750 g to 3.5% for infants 1251 to 1500 g, whereas major morbidity in survivors ranged from 82.7% to 18.7%. In 2009, 49.2% of all very low birth weight infants and 89.2% of infants 501 to 750 g either died or survived with a major neonatal morbidity. CONCLUSIONS: Mortality and major neonatal morbidity in survivors decreased for infants with birth weight 501 to 1500 g between 2000 and 2009. However, at the end of the decade, a high proportion of these infants still either died or survived after experiencing ≥1 major neonatal morbidity known to be associated with both short- and long-term adverse consequences.

Objective To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation. Design Cluster randomised controlled trial Setting and participants 114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001). Main outcome measures Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax. Intervention Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email. Results Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax. Conclusion A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.

Objective. To describe the timing of initial surfactant treatment for high-risk preterm infants in routine practice and compare these findings with evidence from randomized trials and published guidelines.Methods. Data from the Vermont Oxford Network Database for infants who were born from 1998 to 2000 and had birth weights 401 to 1500 g and gestational ages of 23 to 29 weeks were analyzed to determine the time after birth at which the initial dose of surfactant was administered. Multivariate models adjusting for clustering of cases within hospitals identified factors associated with surfactant administration and its timing. Evidence on surfactant timing from systematic reviews of randomized trials and from published guidelines was reviewed.Results. A total of 47 608 eligible infants were cared for at 341 hospitals in North America that participated in the Vermont Oxford Network Database from 1998 to 2000. Seventy-nine percent of infants received surfactant treatment (77.6% in 1998, 79.4% in 1999, and 79.6% in 2000). Factors that increased the likelihood of surfactant treatment were outborn birth, lower gestational age, lower 1-minute Apgar score, male gender, white race, cesarean delivery, multiple birth, or birth later in the study period. The first dose of surfactant was administered at a median time after birth of 50 minutes (60 minutes in 1998, 51 minutes in 1999, and 42 minutes in 2000). Over the 3-year study period, inborn infants received their initial dose of surfactant earlier than outborn infants (median time: 43 minutes vs 79 minutes). Other factors associated with earlier administration of the initial surfactant dose were gestational age, lower 1-minute Apgar score, cesarean delivery, antenatal steroid treatment, multiple birth, and small size for gestational age. In 2000, 27% of infants received surfactant in the delivery room. There was wide variation among hospitals in the proportion of infants who received surfactant treatment in the delivery room (interquartile range: 0%–75%), in the median time of the initial surfactant dose (interquartile range: 20-90 minutes), and in the proportion of infants who received the first dose >2 hours after birth (interquartile range: 7%–34%). Six systematic reviews of randomized trials of surfactant timing were identified. No national guidelines addressing the timing of surfactant therapy were found.Conclusion. Although the time after birth at which the first dose of surfactant is administered to infants 23 to 29 weeks’ gestation decreased from 1998 to 2000, in 2000 many infants still received delayed treatment, and delivery room surfactant administration was not routinely practiced at most units. We conclude that there is a gap between evidence from randomized controlled trials that supports prophylactic or early surfactant administration and what is actually done in routine practice at many units.

In 2006, the Vermont Oxford Network (VON) established the Neonatal Encephalopathy Registry (NER) to characterize infants born with neonatal encephalopathy, describe evaluations and medical treatments, monitor hypothermic therapy (HT) dissemination, define clinical research questions, and identify opportunities for improved care.