Intended for healthcare professionals


Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial

BMJ 2004; 329 doi: (Published 28 October 2004) Cite this as: BMJ 2004;329:1004
  1. Jeffrey D Horbar, chief executive and scientific officer (horbar{at},
  2. Joseph H Carpenter, director of technical operations1,
  3. Jeffrey Buzas, associate professor of mathematics and statistics2,
  4. Roger F Soll, director of clinical trials1,
  5. Gautham Suresh, assistant professor of paediatrics3,
  6. Michael B Bracken, professor of epidemiology4,
  7. Laura C Leviton, senior program officer5,
  8. Paul E Plsek, quality improvement consultant6,
  9. John C Sinclair, professor emeritus7
  1. 1 Vermont Oxford Network, 33 Kilburn Street, Burlington, VT 05401, USA
  2. 2 University of Vermont, Burlington, VT
  3. 3 Medical University of South Carolina, Charleston, SC, USA
  4. 4 Center for Perinatal, Pediatric and Environmental Epidemiology, Yale University, New Haven, CT, USA
  5. 5 Robert Wood Johnson Foundation, Princeton, NJ, USA
  6. 6 Paul E Plsek and Associates, Atlanta, GA, USA
  7. 7 Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to: J D Horbar
  • Accepted 13 July 2004


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.


  • Embedded Image Participants in the Vermont Oxford Network, and details of the intervention workshop appear on

  • Contributors All authors contributed to the planning, conduct, and reporting of this study. JDH is guarantor for the study.

  • Funding Funded by a grant from the Agency for Healthcare Research and Quality (R01 HS10528, Horbar JD, principal investigator). The authors' work was independent of the funding agency.

  • Competing interests JDH is chief executive and scientific officer, RFS is a director, and JHC is an employee of the Vermont Oxford Network. JB received funding for research from the Vermont Oxford Network. RFS has acted as a consultant and spoken at meetings sponsored by various manufacturers of surfactant products, including Ross Laboratory Division of Abbott Laboratories and Chiesi Pharmaceuticals. RFS has also received grant funding from Ross Laboratories to conduct research regarding surfactant therapy. PEP has served as a paid consultant to the Vermont Oxford Network and other clients who sponsor improvement collaboratives. GS has served as a paid consultant to Dey Laboratories, a manufacturer of surfactant.

  • Ethical approval The study was approved by the University of Vermont Institutional Review Board.

  • Accepted 13 July 2004
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