Dubose Joseph, Teixeira Pedro G R, Inaba Kenji, Lam Lydia, Talving Peep, Putty Brad, Plurad David, Green Donald J, Demetriades Demetrios, Belzberg Howard
Division of Trauma and Critical Care at the Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA.
J Trauma. 2010 Oct;69(4):855-60. doi: 10.1097/TA.0b013e3181c4526f.
We have previously demonstrated that the use of a daily "Quality Rounds Checklist" (QRC) can increase compliance with evidence-based prophylactic measures and decrease complications in a busy trauma intensive care unit (ICU) over a 3-month period. This study was designed to determine the sustainability of QRC use over 1 year and examine the relationship between compliance and outcome improvement.
A prospective before-after design was used to examine the effectiveness of the QRC tool in documenting compliance with 16 prophylactic measures for ventilator-associated pneumonia (VAP), deep venous thrombosis, pulmonary embolism, catheter-related bloodstream infection, and other ICU complications. The QRC was implemented on a daily basis for a 1-year period by the ICU fellow on duty. Monthly compliance rates were assessed by a multidisciplinary team for development of strategies for real-time improvement. Compliance and outcomes were captured over 1 year of QRC use.
QRC use was associated with a sustained improvement of VAP bundle and other compliance measures over a year of use. After multivariable analysis adjusting for age (> 55), injury mechanism, Glasgow Coma Scale score (≤ 8), and Injury Severity Score (> 20), the rate of VAP was significantly lower after QRC use, with an adjusted mean difference of -6.65 (per 1,000 device days; 95% confidence interval, -9.27 to -4.04; p = 0.008). During the year of QRC use, 3% of patients developed a VAP if all four daily bundle measures were met for the duration of ICU stay versus 14% in those with partial compliance (p = 0.04). The overall VAP rate with full compliance was 5.29 versus 9.23 (per 1,000 device days) with partial compliance. Compared with the previous year, a 24% decrease in the number of pneumonias was recorded for the year of QRC use, representing an estimated cost savings of approximately $400,000.
The use of a QRC facilitates sustainable improvement in compliance rates for clinically significant prophylactic measures in a busy Level I trauma ICU. The daily use of the QRC, requiring just a few minutes per patient to complete, equates to cost-effective improvement in patient outcomes.
我们之前已经证明，在繁忙的创伤重症监护病房（ICU）中，使用每日“质量巡查清单”（QRC）可提高对循证预防措施的依从性，并在3个月内减少并发症。本研究旨在确定QRC使用超过1年的可持续性，并研究依从性与结局改善之间的关系。
采用前瞻性前后对照设计，以检验QRC工具在记录对16项预防措施的依从性方面的有效性，这些措施针对呼吸机相关性肺炎（VAP）、深静脉血栓形成、肺栓塞、导管相关血流感染及其他ICU并发症。ICU值班住院医师在1年的时间里每天使用QRC。多学科团队每月评估依从率，以制定实时改进策略。在使用QRC的1年时间里记录依从性和结局情况。
在1年的使用期内，QRC的使用与VAP集束方案及其他依从性措施的持续改善相关。在对年龄（>55岁）、损伤机制、格拉斯哥昏迷量表评分（≤8分）和损伤严重程度评分（>20分）进行多变量分析后，使用QRC后VAP发生率显著降低，调整后的平均差异为-6.65（每1000个设备日；95%置信区间，-9.27至-4.04；p=0.008）。在使用QRC的这一年中，如果在ICU住院期间所有四项每日集束措施均得到满足，则3%的患者发生了VAP，而部分依从的患者中这一比例为14%（p=0.04）。完全依从时的总体VAP发生率为每1000个设备日5.29例，部分依从时为9.23例。与上一年相比，使用QRC的这一年记录的肺炎病例数减少了24%，估计节省成本约40万美元。
在繁忙的I级创伤ICU中，使用QRC有助于持续提高对具有临床意义的预防措施的依从率。每天使用QRC，每位患者只需几分钟即可完成，等同于以具有成本效益的方式改善患者结局。
