Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
JAMA. 2011 Jan 26;305(4):363-72. doi: 10.1001/jama.2010.2000. Epub 2011 Jan 19.
Evidence-based practices improve intensive care unit (ICU) outcomes, but eligible patients may not receive them. Community hospitals treat most critically ill patients but may have few resources dedicated to quality improvement.
To determine the effectiveness of a multicenter quality improvement program to increase delivery of 6 evidence-based ICU practices.
DESIGN, SETTING, AND PARTICIPANTS: Pragmatic cluster-randomized trial among 15 community hospital ICUs in Ontario, Canada. A total of 9269 admissions occurred during the trial (November 2005 to October 2006) and 7141 admissions during a decay-monitoring period (December 2006 to August 2007).
We implemented a videoconference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms to sequentially improve delivery of 6 practices. We randomized ICUs into 2 groups. Each group received this intervention, targeting a new practice every 4 months, while acting as control for the other group, in which a different practice was targeted in the same period. MAIN MEASURE OUTCOMES: The primary outcome was the summary ratio of odds ratios (ORs) for improvement in adoption (determined by daily data collection) of all 6 practices during the trial in intervention vs control ICUs.
Overall, adoption of the targeted practices was greater in intervention ICUs than in controls (summary ratio of ORs, 2.79; 95% confidence interval [CI], 1.00-7.74). Improved delivery in intervention ICUs was greatest for semirecumbent positioning to prevent ventilator-associated pneumonia (90.0% of patient-days in last month vs 50.0% in first month; OR, 6.35; 95% CI, 1.85-21.79) and precautions to prevent catheter-related bloodstream infection (70.0% of patients receiving central lines vs 10.6%; OR, 30.06; 95% CI, 11.00-82.17). Adoption of other practices, many with high baseline adherence, changed little.
In a collaborative network of community ICUs, a multifaceted quality improvement intervention improved adoption of care practices.
clinicaltrials.gov Identifier: NCT00332982.
循证实践可改善重症监护病房（ICU）的预后，但符合条件的患者可能并未接受这些实践。社区医院治疗大多数重症患者，但可能几乎没有专门用于质量改进的资源。
确定多中心质量改进计划对提高 6 项基于证据的 ICU 实践的应用效果。
设计、地点和参与者：加拿大安大略省 15 家社区医院 ICU 参与的实用型聚类随机试验。试验期间共发生 9269 例入住（2005 年 11 月至 2006 年 10 月），衰减监测期间发生 7141 例入住（2006 年 12 月至 2007 年 8 月）。
我们实施了一个基于视频会议的论坛，包括审核和反馈、专家主导的教育会议以及算法的传播，以逐步提高 6 项实践的应用。我们将 ICU 随机分为 2 组。每组都接受该干预措施，每 4 个月针对一项新实践，同时作为对照组，同一时期针对另一项不同的实践。
主要结局是试验期间干预组与对照组 ICU 中所有 6 项实践采用（通过每日数据收集确定）的比值比（OR）的综合比值。
总体而言，干预组 ICU 的目标实践采用率高于对照组（综合 OR，2.79；95%置信区间[CI]，1.00-7.74）。干预组 ICU 中，半卧位预防呼吸机相关性肺炎（最后 1 个月中 90.0%的患者日 vs 第 1 个月中 50.0%；OR，6.35；95%CI，1.85-21.79）和预防导管相关血流感染的措施（接受中心静脉置管的患者中 70.0% vs 10.6%；OR，30.06；95%CI，11.00-82.17）的改善最大。其他实践的采用率，许多实践在开始时的依从性就很高，变化很小。
在社区 ICU 的协作网络中，多方面的质量改进干预措施提高了护理实践的采用率。
clinicaltrials.gov 标识符：NCT00332982。
