title: The quest for sustained multiple morbidity reduction in very low-birth-weight infants: the Antifragility project.
abstract: Can a comprehensive, explicitly directive evidence-based guideline for all therapies that might affect the major morbidities of very low-birth-weight (VLBW) infants help a neonatal intensive care unit (NICU) further improve generally favorable morbidity rates? Can Antifragility principles of provider adaptive growth from stressors, enhanced infant risk assessment and adherence to effective therapies minimize unproven treatments and reduce all morbidities?
  
  
  
  Prospectively planned observational trial in VLBW infants: control group born October 2011 to September 2013 and study group October 2013 to September 2015. Multi-disciplinary evidence-based review assigned all NICU treatments into one of four distinct categories: (1) always employ this therapy for VLBW infants, (2) never use this therapy, (3) employ this questionable therapy thoughtfully, only in certain circumstances and (4) this therapy has insufficient evidence of efficacy and safety. Extensive staff education emphasized evidence-based potentially better practice (PBP) selection with compliance checks, appreciation of intertwined co-morbidities and prioritizing infant risk reduction strategies.
  
  
  
  Control included 221 infants, mean (s.d.) age 29 (2.6) weeks, birth weight 1129 (257) g and Study included 197 infants, 29 (2.7) weeks, 1093 (292) g. One hundred and four distinct therapies were placed into categories 1 to 4, with 32 specific compliance checks. Overall mean compliance with the process checks during the second era was 70%, high: 100% (exclusive breast milk use), low: 24% (correct pulse oximetry alarm settings). Morbidity and mortality rates did not significantly change during the second era.
  
  
  
  In our NICU with favorable morbidity rates, an expanded effort using a comprehensive therapy guideline for VLBW infants did not further improve outcomes. We need deeper understanding of continuous quality improvement (CQI) fundamentals, therapy compliance, co-morbidity relationships and enhanced sensitivity of risk assessment. Our innovative Antifragility PBP guideline could be useful to other NICUs seeking improvement in VLBW infant morbidities, as we offer a reasoned and concise template of a broad array of therapies categorized efficiently for transparency and review, designed to enhance responsible CQI decision-making.
authors.affiliation: Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA.
authors.forename: J W
authors.initials: JW
authors.lastname: Kaempf
authors.affiliation: Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA.
authors.forename: N M
authors.initials: NM
authors.lastname: Schmidt
authors.affiliation: Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA.
authors.forename: S
authors.initials: S
authors.lastname: Rogers
authors.affiliation: Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA.
authors.forename: C
authors.initials: C
authors.lastname: Novack
authors.affiliation: Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA.
authors.forename: M
authors.initials: M
authors.lastname: Friant
authors.affiliation: Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA.
authors.forename: L
authors.initials: L
authors.lastname: Wang
authors.affiliation: Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA.
authors.forename: N
authors.initials: N
authors.lastname: Tipping
mesh_terms: D001724:Birth Weight; D005260:Female; D005865:Gestational Age; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal / Q000458:organization & administration; D008297:Male; D009017:Morbidity; D000071069:Multiple Chronic Conditions / Q000145:classification* / Q000401:mortality*; D009922:Oregon / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D058996:Quality Improvement / Q000458:organization & administration / Q000592:standards*