Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
Crit Care. 2011;15(6):316. doi: 10.1186/cc10582. Epub 2011 Dec 9.
Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NK, Zwarenstein M: A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA 2011, 305:363-72.
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 to devote 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).
The authors implemented a videoconference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms to sequentially improve delivery of 6 practices. The ICUs were randomized 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.
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 semi recumbent 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 multi-faceted quality improvement intervention improved adoption of care practices.
Scales DC、Dainty K、Hales B、Pinto R、Fowler RA、Adhikari NK、Zwarenstein M：一项针对重症监护病房网络的多方面质量改进干预措施：一项集群随机试验。JAMA 2011，305：363-72。
循证实践可改善重症监护病房（ICU）的结局，但符合条件的患者可能无法接受这些实践。社区医院治疗大多数危重症患者，但可能几乎没有资源用于质量改进。
确定一种多中心质量改进计划，以增加 6 项循证 ICU 实践的实施。
设计、地点和参与者：在加拿大安大略省的 15 家社区医院 ICU 中进行了一项实用的集群随机试验。试验期间共发生 9269 例住院（2005 年 11 月至 2006 年 10 月），在衰减监测期间（2006 年 12 月至 2007 年 8 月）发生了 7141 例住院。
作者实施了一个基于视频会议的论坛，包括审计和反馈、专家主导的教育课程以及算法的传播，以逐步提高 6 项实践的实施。将 ICU 随机分为 2 组。每组均接受此干预措施，每 4 个月针对一项新实践，同时作为对照组，在同一时期针对另一项不同的实践。
主要结局是在试验中干预组与对照组 ICU 中所有 6 项实践的采用（通过每日数据收集确定）改善的综合比值比（OR）。
总体而言，干预组 ICU 的目标实践采用率高于对照组（综合 OR 比，2.79；95%置信区间 [CI]，1.00-7.74）。干预组 ICU 中最大的改进是半卧位预防呼吸机相关性肺炎（最后一个月的患者天数为 90.0%，第一个月为 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有 70.0%；OR，30.06；95%CI，11.00-82.17）。其他实践的采用率，许多实践的采用率已经很高，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。
