The Vermont Oxford Network: A Community of Practice

https://doi.org/10.1016/j.clp.2010.01.003Get rights and content

Section snippets

VLBW Database

Infants are eligible for the VLBW database if they have a birth weight from 401 to 1500 g, or a gestational age between 22 and 29 weeks, and are born at the member hospital or are transferred to it within 28 days of birth. Infants born at a participating hospital who die in the delivery room or before NICU admission are included.

The characteristics of infants weighing 501 to 1500 g born in 2008 reported by the 750 institutions participating in the Network for that year are shown in Table 2,

Expanded Database for all NICU infants

In 2008, 241 hospitals participated in the Vermont Oxford Network Expanded Database and reported on nearly 106,000 infants born in the hospital who were treated in the NICU or died before admission, or who were transferred to the NICU from another hospital within 28 days of birth. The respiratory interventions and outcomes by birth weight category for these infants are shown in Table 4. Again, marked variation among hospitals is apparent for many of the items.

It is important to recognize that

Data submission

All Vermont Oxford Network members have free access to eNICQ, a locally installed application that supports the collection, editing, and submission of Vermont Oxford Network data. Only de-identified data are exported to the Vermont Oxford Network. Currently more than 650 members are using eNICQ to manage Network data collection and submission. eNICQ is compatible with other NICU information systems and in the future will be integrated with electronic health records of specific systems.

Risk adjustment

Variation has been found in almost every area of medical practice that has been studied.2, 3 The NICU is no exception. There are several potential sources for the observed variations in intervention and outcome. These include differences in the severity of illness (case mix), chance, and differences in the quality or effectiveness of care. If the differences due to case mix and chance can be adequately account for the residual unexplained variation may be a valuable indicator of differences in

Database research

The Vermont Oxford Network databases provide a platform for observational studies and outcomes research. These observational studies have addressed trends over time,9, 10 outcomes in various groups of interest,11, 12, 13, 14 and the diffusion, use, and effect of various interventions.15, 16, 17, 18 The Vermont Oxford Network has conducted research to assess the contribution of differences in the structure and organization of the NICU to variations in patient outcomes. These have included

Member reporting

The Vermont Oxford Network provides members with detailed confidential reports that allow them to track their data over time, compare their performance with a large group of NICUs around the world, and with smaller groups of NICUs with characteristics similar to their own. These reports include unadjusted and adjusted data.

All members receive quarterly and annual reports in print or on CD ROM and have access to real-time reporting on the Vermont Oxford Network Internet Reporting System,

Nightingale

Members have access to their data in real time using the secure and confidential Nightingale Internet Reporting System. A sample screen from Nightingale for a fictitious center 999 is shown in Fig. 4. The control menu allows a user to select different populations and years of birth for review. Center-specific data and data for a comparison group are displayed. The comparison group is chosen from a pull-down menu. Choices include the entire Network, NICUs of a specific NICU type, NICUs in the

Quality improvement

Quality improvement has been a major focus for the Vermont Oxford Network in the last 15 years.24 The activities have included 6 intensive multidisciplinary Neonatal Intensive Care Quality (NICQ) Collaboratives, and a series of 9 Internet-based iNICQ collaboratives. The activities and work products of these collaboratives are available to Vermont Oxford Network members online and are presented at the Annual Quality Congresses held in conjunction with the annual Vermont Oxford Network Members

National Quality Measures

Several national organizations including the National Quality Forum (NQF)39 and the Leapfrog Group40 have developed standard measures for institutions to use in monitoring and improving quality and safety. Both of these organizations have included Vermont Oxford Network data items as measurement options. The Leapfrog Group allows participants in their survey to use the Vermont Oxford Network data on antenatal steroid treatment for addressing the high-risk delivery process measure for quality.

Randomized controlled trials

Trials of health care interventions can be described as either explanatory or pragmatic. Explanatory trials generally measure efficacy: the benefit a treatment produces under ideal conditions, often using carefully defined subjects in a research setting. Pragmatic trials measure effectiveness: the benefit of treatment produced in routine clinical practice. The Vermont Oxford Network is committed to performing pragmatic trials of available therapies to evaluate clinically important outcomes. The

Follow-up

In keeping with the pragmatic nature of the database and randomized trials, the Vermont Oxford Network has created a pragmatic follow-up program. Many published estimates of death and developmental outcome are from well-funded university programs and may not reflect outcomes of infants from various settings. The goal of the follow-up networks was to describe the neurodevelopmental outcome of extremely low-birth-weight infants from centers in the Vermont Oxford Network and to identify

Worldwide community of practice

Wenger48 has defined a community of practice as groups “formed by people who engage in a process of collective learning in a shared domain of human endeavor: a tribe learning to survive, a band of artists seeking new forms of expression, a group of engineers working on similar problems, a clique of pupils defining their identity in the school, a network of surgeons exploring novel techniques, a gathering of first-time managers helping each other cope. In a nutshell: groups of people who share a

Acknowledgment

The authors recognize and thank the health professionals and families at member hospitals in Vermont Oxford Network for their dedication to improving the quality and safety of NICU care and for making the work described in this article possible.

First page preview

First page preview
Click to open first page preview

References (48)

  • J. Simpson et al.

    Analysing differences in clinical outcomes between hospitals

    Qual Saf Health Care

    (2003)
  • D.K. Richardson et al.

    Birth weight and illness severity: independent predictors of neonatal mortality

    Pediatrics

    (1993)
  • J.A.F. Zupancic et al.

    Revalidation of the score for neonatal acute physiology in the Vermont Oxford Network

    Pediatrics

    (2007)
  • J.D. Horbar et al.

    Trends in mortality and morbidity for very low birth weight infants, 1991–1999

    Pediatrics

    (2002)
  • M.C. Walsh et al.

    Changes in the use of postnatal steroids for bronchopulmonary dysplasia in 3 large neonatal networks

    Pediatrics

    (2006)
  • J.F. Lucey et al.

    Fetal infants: the fate of 4172 infants with birth weights of 401 to 500 grams: the Vermont Oxford Network experience (1996–2000)

    Pediatrics

    (2004)
  • S.C. Fitzgibbons et al.

    Mortality of necrotizing enterocolitis expressed by birth weight categories

    J Pediatr Surg

    (2009)
  • J.D. Horbar et al.

    Increasing use of antenatal corticosteroid therapy between 1990 and 1993 in the Vermont Oxford Network

    J Perinatol

    (1997)
  • N.N. Finer et al.

    Cardiopulmonary resuscitation in the very low birth weight infant: The Vermont Oxford Network experience

    Pediatrics

    (1999)
  • J.D. Horbar et al.

    Timing of initial surfactant treatment for infants 23 to 29 weeks gestation: is routine practice evidence-based?

    Pediatrics

    (2004)
  • J.D. Horbar et al.

    Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants

    Pediatrics

    (1997)
  • J.A. Rogowski et al.

    Indirect versus direct hospital quality indicators for very low birth weight infants

    JAMA

    (2004)
  • J.A. Rogowski et al.

    Variations in the quality of care for very low birth weight infants: implications for policy

    Health Aff

    (2004)
  • L.S. Morales et al.

    Mortality among very low birthweight infants in hospitals serving minority population

    Am J Public Health

    (2005)
  • Cited by (0)

    Drs Horbar, Soll and Edwards are the Directors of the Vermont Oxford Network.

    View full text