When patients experience severe and debilitating diseases or undergo critical procedures, they are often hospitalized in the intensive care unit (ICU). Despite receiving expensive life-sustaining technologies once patients are admitted to the ICU, mortality and complication rates in critically ill patients remain high.
As a result, the authors of a recent paper published in the Journal of the American Medical Association (JAMA) identified a need for ICU patients to receive evidence-based and cost-effective interventions that improve outcomes. However, the authors of the paper, entitled “A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units,” recognized a number of barriers that exist, which make the use of evidence-based medicine and cost-effective interventions difficult.
For example, the authors recognized that changing clinical behavior in ICUs to improve quality is difficult because there is usually a diverse group of clinicians and an interprofessional team that provides care to patients in the ICU. This diversity makes it hard to identify the best methods and strategies to target different barriers to behavior change. Another problem the authors identified is that nonacademic hospitals face larger barriers to implementing evidence-based care because of heavier individual clinician workloads and fewer personnel devoted to collaborative continuing educational activities.
To address the gaps in care in ICUs, the authors designed and delivered a quality improvement intervention to 15 community hospital ICUs in Ontario, Canada, and included a wide range of facilities operating under usual care conditions. The participating ICUs were of variable size (range of staffed beds, 4-19) and located within 15 geographically dispersed Ontario community hospitals (representing 15.5% of community hospitals and 19.9% of community hospital ICU beds in Ontario). One medical-surgical ICU from each hospital was involved in the study and there was a total of 9269 ICU admissions during the trial.
Considering all hospitals and targeted care practices, the study’s primary conclusion was that “patients in ICUs receiving active intervention were more likely to receive the targeted care practice than those in contemporaneous control ICUs receiving an active intervention for a different practice.” This finding indicates that quality improvement initiatives and continuing medical education (CME) can help bring about the implementation of evidence-based care to help control costs and save lives.
Study Design
The quality improvement intervention was designed specifically to target the entire ICU team and to be feasible in a broad range of ICUs. The study conducted a cluster-randomized pragmatic trial to determine whether this intervention could increase ICU adoption of 6 evidence-based care practices:
– Prevention of ventilator-associated pneumonia (VAP)
– Prevention of deep vein thrombosis (DVT
– Sterile precautions for central venous catheter insertion to prevent catheter-related bloodstream infections
– Daily spontaneous breathing trials to decrease duration of mechanical ventilation
– Early enteral nutrition
– Daily assessment of risk for developing decubitus (pressure) ulcers.
The study was funded as a demonstration project by the Critical Care Secretariat of the Ontario Ministry of Health and Long-Term Care to improve quality of care and foster system integration.
The trial ran from November 1, 2005, to October 31, 2006, during which the 2 groups of ICUs were randomly assigned to receive active interventions to improve adoption of the different care practices. During each phase of the trial, each group of ICUs received the active behavior change intervention targeting one care practice and simultaneously acted as a control group for the other group of ICUs that received the active behavior change intervention targeting a different care practice. This avoided randomizing a group of ICUs to no intervention, which could have been demoralizing to the participating ICUs.
The authors used the Ontario Telemedicine Network videoconferencing infrastructure to conduct the intervention, including live interactive educational sessions from content experts for each targeted care practice, monthly network meetings, and training sessions for site educators. The interactive educational sessions were recorded and available for subsequent Web-based access.
Results
During each 4-month phase of the trial, the study determined the difference in the change in proportion of patients receiving each targeted care practice in the intervention ICUs compared with the same practice in control ICUs. The study focused on comparing rates of change between intervention and control ICUs because the study interventions were expected to change behavior over time (and not instantaneously) and because ICU performance at the end of each phase must be adjusted for performance at the beginning.
Prevention of VAP: The overall rate of adherence to semirecumbent positioning in the intervention ICUs improved from 49.8% in the first month to 89.6% during the last month vs. from 80.1% to 90.2% in the control ICUs.
Prophylaxis Against DVT: Overall, there was no change in the proportion of eligible patients receiving DVT prophylaxis among intervention ICUs or among control ICUs; the rate of improvement was similar.
Prevention of Catheter-Related Bloodstream Infections: The overall rate of adherence to all 7 components of the catheter insertion bundle improved from 10.0% during the first month to 70.6% during the last month in intervention ICUs vs. 31.0% in the first month to 51.7% in the last month in control ICUs.
Daily Spontaneous Breathing Trials: There was no overall difference in the rate of improvement for successful extubation or performance of a spontaneous breathing trial.
Decubitus Ulcer Risk Assessments: There was no difference in intervention ICUs and no difference between intervention and control ICUs.
Provision of Early Enteral Nutrition: No improvements in this practice in ICUs receiving active interventions from the first month to the last month. Similarly, no improvements were observed over time in control, and rates of improvements were similar comparing active and control ICUs.
Discussion
The authors concluded that the cluster-randomized pragmatic trial with active controls demonstrated that a multifaceted quality improvement intervention including education, reminders, and audit and feedback through a collaborative telecommunication network improved the delivery of evidence-based care practices in community ICUs. The improvements were greatest for practices to prevent catheter-related bloodstream infections and ventilator-associated pneumonia.
The study demonstrated a number of strengths, including an intervention that was a comprehensive quality improvement package, which targeted multiple disparate care practices rather than a single quality measure. Additionally, the study always engaged ICUs in quality improvements and ensured that all ICUs would receive active strategies targeting all 6 care practices. A possible limitation of the study the authors noted was that a longer intervention phase and inclusion of more study centers would have narrowed the results. They also noted that ICUs receiving direct monitoring may have had “Hawthorne effects,” which improved adherence in control ICUs and thus reduced the effect of the intervention.
Conclusion
The authors concluded from the data “that a collaborative network of ICUs linked by a telecommunication infrastructure improved the adoption of care practices.” Ultimately, the data from this report show that CME, Quality Improvement, and social learning lead to vastly improved evidence-based care that helps improve and save lives.