title: Critical Illness Outcome Study: An Observational Study on Protocols and Mortality in Intensive Care Units.
abstract: BACKGROUND
  Many individual Intensive Care Unit (ICU) characteristics have been associated with patient outcomes, including staffing, expertise, continuity and team structure. Separately, many aspects of clinical care in ICUs have been operationalized through the development of complex treatment protocols. The United State Critical Illness and Injury Trials Group-Critical Illness Outcomes Study (USCIITG-CIOS) was designed to determine whether the extent of protocol availability and use in ICUs is associated with hospital survival in a large cohort of United States ICUs. Here, we describe the study protocol and analysis plan approved by the USCIITG-CIOS Steering Committee.
  
  
  METHODS
  USCIITG-CIOS is a prospective, observational, ecological multi-centered "cohort" study of mixed ICUs in the U.S. The data collected include organizational information for the ICU (e.g., protocol availability and utilization, multi-disciplinary staffing assessment) and patient level information (e.g. demographics, acute and chronic medical conditions). The primary outcome is all-cause hospital mortality, with the objective being to determine whether there is an association between protocol number and hospital mortality for ICU patients. USCIITG-CIOS is powered to detect a 3% difference in crude hospital mortality between high and low protocol use ICUs, dichotomized according to protocol number at the median. The analysis will utilize regression modeling to adjust for outcome clustering by ICU, with secondary linear analysis of protocol number and mortality and a variety ofa prioriplanned ancillary studies. There are presently 60 ICUs participating in USCIITG-CIOS to enroll approximately 6,000 study subjects.
  
  
  CONCLUSIONS
  USCIITG-CIOS is a large multicentric study examining the effect of ICU protocol use on patient outcomes. The primary results of this study will inform our understanding of the relationship between protocol availability, use, and patient outcomes in the ICU. Moreover, given the shortage of intensivists worldwide, the results of USCIITG-CIOS can be used to promote more effective ICU and care team design and will impact the delivery of intensive care services beyond individual practitioners.
  
  
  BACKGROUND
  ClinicalTrials.gov Identifier NCT01109719.
authors.affiliation: The Ohio State University Medical Center, Columbus, OH.
authors.forename: Naeem A
authors.initials: NA
authors.lastname: Ali
authors.affiliation: Emory University, Atlanta, GA.
authors.forename: David
authors.initials: D
authors.lastname: Gutteridge
authors.affiliation: Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Sajid
authors.initials: S
authors.lastname: Shahul
authors.affiliation: Johns Hopkins University, Baltimore, MD.
authors.forename: William
authors.initials: W
authors.lastname: Checkley
authors.affiliation: Johns Hopkins University, Baltimore, MD.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sevransky
authors.affiliation: Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Greg S
authors.initials: GS
authors.lastname: Martin
keywords: Critical Care; ICU; ICU organization; Outcomes; Protocols