title: A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care.
abstract: BACKGROUND
  Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards.
  
  
  METHODS
  In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs.
  
  
  RESULTS
  We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group).
  
  
  CONCLUSIONS
  A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up.
  
  
  BACKGROUND
  
  ISRCTN50542146.
authors.affiliation: Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, PO Box 90153, , 5000 LE, Tilburg, The Netherlands. mdevos@amphia.nl.|Center for Prevention and Health Services Research, National Institute for Public Health and the Environment, PO Box 1, , 3720 BA, Bilthoven, The Netherlands. mdevos@amphia.nl.
authors.forename: Maartje L G
authors.initials: ML
authors.lastname: de Vos
authors.affiliation: Department of Medical Informatics, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, The Netherlands. s.n.vanderveer@amc.nl.
authors.forename: Sabine N
authors.initials: SN
authors.lastname: van der Veer
authors.affiliation: Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, PO Box 90153, , 5000 LE, Tilburg, The Netherlands. b.wouterse@cpb.nl.|Center for Public Health Forecasting, National Institute for Public Health and the Environment, PO Box 1,, 3720 BA, Bilthoven, The Netherlands. b.wouterse@cpb.nl.
authors.forename: Bram
authors.initials: B
authors.lastname: Wouterse
authors.affiliation: Health Strategy and Health Systems Unit, European Commission, Brussels, Belgium. wgraafmans@zinl.nl.
authors.forename: Wilco C
authors.initials: WC
authors.lastname: Graafmans
authors.affiliation: Health e-Research Centre, The University of Manchester, Manchester, UK. n.b.peek@amc.uva.nl.
authors.forename: Niels
authors.initials: N
authors.lastname: Peek
authors.affiliation: Department of Medical Informatics, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, The Netherlands. n.f.keizer@amc.uva.nl.
authors.forename: Nicolette F
authors.initials: NF
authors.lastname: de Keizer
authors.affiliation: Department of Medical Informatics, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, The Netherlands. k.j.jager@amc.uva.nl.
authors.forename: Kitty J
authors.initials: KJ
authors.lastname: Jager
authors.affiliation: Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. g.westert@iq.umcn.nl.
authors.forename: Gert P
authors.initials: GP
authors.lastname: Westert
authors.affiliation: Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, PO Box 95500, , 1090 HM, Amsterdam, The Netherlands. p.h.j.vandervoort@olvg.nl.|TIAS School for Business and Society, Tilburg University, Tilburg, The Netherlands. p.h.j.vandervoort@olvg.nl.
authors.forename: Peter H J
authors.initials: PH
authors.lastname: van der Voort
mesh_terms: D001509:Bed Occupancy / Q000592:standards; D064648:Critical Care Nursing / Q000592:standards / Q000706:statistics & numerical data; D005246:Feedback; D019983:Guideline Adherence / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data; D009426:Netherlands; D058996:Quality Improvement