A multi-pronged quality improvement program helped community hospitals adopt six evidence-based practices in the ICU, a new study reports.
The targeted care practices (with process-of-care indicators) were prevention of ventilator-associated pneumonia (indicators: semirecumbent positioning, orotracheal intubation); prophylaxis for deep vein thrombosis (indicators: anticoagulant administration, antiembolic stockings if anticoagulants were contraindicated); daily spontaneous breathing trials (indicators: spontaneous breathing trial or extubation within the last 24 hours); preventing catheter-related bloodstream infections (indicators: completing 7-point checklist for sterile insertion, fulfilling all 7 checklist criteria, anatomical site of catheter insertion); early enteral feeding (indicator: initiation of enteral feeding within 48 hours of ICU admission); and decubitus ulcer prevention (indicator: completion of the Braden index at least twice a day).
In the cluster-randomized trial of 15 community hospital intensive care units (ICUs) in Ontario, Canada, researchers examined 9,269 admissions over 12 months, and 7,141 admissions over a separate decay-monitoring period of nine months. To improve the six care practices, they used a videoconference-based forum with auditing and feedback, expert-led educational sessions, and disbursement of algorithms. ICUs were randomized into two groups. Each group received the intervention, which targeted a new practice every four months, and also acted as a control for another group in which a different practice was targeted in the same time period. The six practices were paired to minimize the potential for quality improvement efforts that targeted one practice to influence process measures related to the other practice.
Adoption of targeted practices was greater in intervention ICUs than in controls (summary ratio of odds ratios [ORs], 2.79; 95% CI, 1.00 to 7.74). In intervention ICUs, care delivery improved the most 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 to 21.79) and precautions to prevent catheter-related bloodstream infection (70% of patients receiving central lines vs. 10.6%; OR, 30.06; 95% CI, 11.00 to 82.17). Adoption of other practices didn't change much, but several already had high baseline adherence. Results were published online Jan. 19 in the Journal of the American Medical Association.
The success of the intervention is noteworthy in that it occurred in community (not academic) ICUs, which admit the majority of critically ill patients, the authors noted. Further, the videoconferencing aspect of the intervention can help health care workers in geographically dispersed hospitals access resources that are usually restricted to academic facilities, they noted. Post hoc analyses indicate the intervention had the largest effect in ICUs with low baseline adherence to certain practices, suggesting similar initiatives should target these types of ICUs and practices, the authors wrote. Generally, large-scale quality improvement initiatives “should choose practices based on measured rather than reported care gaps, consider site-specific (vs. aggregated) needs assessments to determine target care practices, and conduct baseline audits to focus on poorly performing ICUs,” the authors concluded.