A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial.
BACKGROUND
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.


OBJECTIVE
To determine the effectiveness of a multicenter quality improvement program to increase delivery of 6 evidence-based ICU practices.


METHODS
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).


METHODS
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.


RESULTS
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.


CONCLUSIONS
In a collaborative network of community ICUs, a multifaceted quality improvement intervention improved adoption of care practices.


BACKGROUND
clinicaltrials.gov Identifier: NCT00332982.
Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. damon.scales@utoronto.ca
Damon C
DC
Scales
Katie
K
Dainty
Brigette
B
Hales
Ruxandra
R
Pinto
Robert A
RA
Fowler
Neill K J
NK
Adhikari
Merrick
M
Zwarenstein
D000368:Aged; D000369:Aged, 80 and over; D055499:Catheter-Related Infections / Q000517:prevention & control; D019317:Evidence-Based Medicine; D005246:Feedback; D005260:Female; D019983:Guideline Adherence; D006764:Hospitals, Community / Q000592:standards; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D016017:Odds Ratio; D009864:Ontario; D017063:Outcome Assessment, Health Care; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control; D058996:Quality Improvement; D013685:Telecommunications