title: Evaluation Following Staggered Implementation of the "Rethinking Critical Care" ICU Care Bundle in a Multicenter Community Setting.
abstract: OBJECTIVE
  To evaluate process metrics and outcomes after implementation of the "Rethinking Critical Care" ICU care bundle in a community setting.
  
  
  METHODS
  Retrospective interrupted time-series analysis.
  
  
  METHODS
  Three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system.
  
  
  METHODS
  ICU patients admitted between January 1, 2009, and August 30, 2013.
  
  
  METHODS
  Implementation of the Rethinking Critical Care ICU care bundle which is designed to reduce potentially preventable complications by focusing on the management of delirium, sedation, mechanical ventilation, mobility, ambulation, and coordinated care. Rethinking Critical Care implementation occurred in a staggered fashion between October 2011 and November 2012.
  
  
  RESULTS
  We measured implementation metrics based on electronic medical record data and evaluated the impact of implementation on mortality with multivariable regression models for 24,886 first ICU episodes in 19,872 patients. After implementation, some process metrics (e.g., ventilation start and stop times) were achieved at high rates, whereas others (e.g., ambulation distance), available late in the study period, showed steep increases in compliance. Unadjusted mortality decreased from 12.3% to 10.9% (p < 0.01) before and after implementation, respectively. The adjusted odds ratio for hospital mortality after implementation was 0.85 (95% CI, 0.73-0.99) and for 30-day mortality was 0.88 (95% CI, 0.80-0.97) compared with before implementation. However, the mortality rate trends were not significantly different before and after Rethinking Critical Care implementation. The mean duration of mechanical ventilation and hospital stay also did not demonstrate incrementally greater declines after implementation.
  
  
  CONCLUSIONS
  Rethinking Critical Care implementation was associated with changes in practice and a 12-15% reduction in the odds of short-term mortality. However, these findings may represent an evaluation of changes in practices and outcomes still in the midimplementation phase and cannot be directly attributed to the elements of bundle implementation.
authors.affiliation: 1Division of Research, Kaiser Permanente, Oakland, CA.2The Permanente Medical Group, Kaiser Permanente, Oakland, CA.3Kaiser Foundation Hospitals and Health Plan, Kaiser Permanente, Oakland, CA.4Decision Support, Kaiser Permanente, Oakland, CA.
authors.forename: Vincent
authors.initials: V
authors.lastname: Liu
authors.forename: David
authors.initials: D
authors.lastname: Herbert
authors.forename: Anne
authors.initials: A
authors.lastname: Foss-Durant
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Marelich
authors.forename: Anandray
authors.initials: A
authors.lastname: Patel
authors.forename: Alan
authors.initials: A
authors.lastname: Whippy
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Turk
authors.forename: Arona I
authors.initials: AI
authors.lastname: Ragins
authors.forename: Patricia
authors.initials: P
authors.lastname: Kipnis
authors.forename: Gabriel J
authors.initials: GJ
authors.lastname: Escobar
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002140:California; D003422:Critical Care / Q000458:organization & administration*; D003693:Delirium / Q000517:prevention & control; D019033:Delivery of Health Care, Integrated; D005260:Female; D006284:Health Plan Implementation / Q000458:organization & administration*; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration / Q000592:standards*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods; D064872:Patient Care Bundles / Q000379:methods; D058996:Quality Improvement; D012121:Respiration, Artificial / Q000009:adverse effects; D012189:Retrospective Studies