Quality improvement project to reduce intraventricular haemorrhage in very preterm infants failed due to increased life-sustaining intensive care at low gestational age

Objectives: In October 2016, a single centre quality improvement programme ‘IBIS’ (from the German “Intraventrikuläre Blutungs-Inzidenz Senken”), an intraventricular haemorrhage (IVH) prevention bundle had the Specific Measurable Achievable Reasonable Time-bound (SMART) Aim to reduce IVH incidence from 29.6% to 18.5% within 2 years for very preterm (gestational age (GA) between 23 0/7 and 29 6/7). Design: Monocentric retrospective cohort study of a failed quality improvement project using prospectively collected data including 1276 live-born very preterm infants between 2010 and 2023. Primary outcome measures were IVH, severe IVH and death or severe IVH. Statistical analysis included propensity score matching. Interventions: IBIS, an ongoing IVH prevention bundle based on a systematic literature search starting in October 2016. Results: Comparing pre-IBIS patients (2010–September 2016) to IBIS patients (October 2016–2023) revealed no reduction in IVH (25.1% vs 25.1%) or severe IVH (9.6% vs 9.1%). Instead, mortality (24.8% vs 13%) and delivery room mortality (9% vs 5%) were almost halved and fewer infants died after primary palliative care (8.5% vs 4.7%) or after redirection from intensive to palliative care (15.1% vs 7.9%). Longitudinal analysis revealed no trends for IVH or severe IVH over the entire period. Limiting the analysis to the IBIS period reveals a significant trend for fewer IVH (p=0.001). Propensity score matching revealed significant reduction for severe IVH (OR 0.62, 95% CI 0.39 to 0.99) and death or severe IVH (OR 0.42, 95% CI: 0.3 to 0.59) but not for IVH. Conclusions: The IBIS SMART Aim to reduce IVH failed. Simultaneously, survival was significantly increased by the increased provision of life-sustaining intensive care at lower GAs, which possibly led to an increased risk for acquiring IVH. Our results highlight the need for a better understanding of the effects of extending perinatal interventional activity to lower GAs on adverse outcome monitoring.