Measurable outcomes of quality improvement using a daily quality rounds checklist: one-year analysis in a trauma intensive care unit with sustained ventilator-associated pneumonia reduction.
BACKGROUND
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Dubose
Joseph
J
Division of Trauma and Critical Care at the Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA. jjd3c@yahoo.com
Teixeira
Pedro G R
PG
Inaba
Kenji
K
Lam
Lydia
L
Talving
Peep
P
Putty
Brad
B
Plurad
David
D
Green
Donald J
DJ
Demetriades
Demetrios
D
Belzberg
Howard
H
D000046:Academic Medical Centers; D000293:Adolescent; D000328:Adult; D000368:Aged; D002140:California; D057189:Checklist; D003428:Cross Infection / Q000401:mortality / Q000517:prevention & control; D019317:Evidence-Based Medicine / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000592:standards; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000401:mortality* / Q000517:prevention & control*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards*; D014947:Wounds and Injuries / Q000401:mortality* / Q000628:therapy; D055815:Young Adult