Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study.
OBJECTIVE
Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs.


METHODS
Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients' data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score.


RESULTS
ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15-0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904-0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased.


CONCLUSIONS
In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.
Marcio
M
Soares
Fernando A
FA
Bozza
Derek C
DC
Angus
André M
AM
Japiassú
William N
WN
Viana
Roberto
R
Costa
Leonardo
L
Brauer
Bruno F
BF
Mazza
Thiago D
TD
Corrêa
André L  B
AL
Nunes
Thiago
T
Lisboa
Fernando
F
Colombari
Alexandre T
AT
Maciel
Luciano C P
LC
Azevedo
Moyzés
M
Damasceno
Haggeas S
HS
Fernandes
Alexandre B
AB
Cavalcanti
Pedro E A  A
PE
do Brasil
Jeremy M
JM
Kahn
Jorge I  F
JI
Salluh
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001938:Brazil; D015331:Cohort Studies; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies