Effect of a Quality Improvement Intervention With Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients

Made available in DSpace on 2021-06-25T10:32:46Z (GMT). No. of bitstreams: 0 Previous issue date: 2016-04-12 Asian Development Bank American Dysautonomia Institute Armed Forces Health Surveillance Branch Health Systems Institute ACG Institute for Clinical Research and Education Ministério da Saúde IMPORTANCE: The effectiveness of checklists, daily goal assessments, and clinician prompts as quality improvement interventions in intensive care units (ICUs) is uncertain. OBJECTIVE: To determine whether a multifaceted quality improvement intervention reduces the mortality of critically ill adults. DESIGN, SETTING, AND PARTICIPANTS: This study had 2 phases. Phase 1 was an observational study to assess baseline data on work climate, care processes, and clinical outcomes, conducted between August 2013 and March 2014 in 118 Brazilian ICUs. Phase 2 was a cluster randomized trial conducted between April and November 2014 with the same ICUs. The first 60 admissions of longer than 48 hours per ICU were enrolled in each phase. INTERVENTIONS: Intensive care units were randomized to a quality improvement intervention, including a daily checklist and goal setting during multidisciplinary rounds with follow-up clinician promptingfor 11 care processes, or to routine care. MAIN OUTCOMES AND MEASURES: In-hospital mortality truncated at 60 days (primary outcome) was analyzed using a random-effects logistic regression model, adjusted for patients' severity and the ICU's baseline standardized mortality ratio. Exploratory secondary outcomes included adherence to care processes, safety climate, and clinical events. RESULTS: A total of 6877 patients (mean age, 59.7 years; 3218 [46.8%] women) were enrolled in the baseline (observational) phase and 6761 (mean age, 59.6 years; 3098 [45.8%] women) in the randomized phase, with 3327 patients enrolled in ICUs (n = 59) assigned to the intervention group and 3434 patients in ICUs (n = 59) assigned to routine care. There was no significant difference in in-hospital mortality between the intervention group and the usual care group, with 1096 deaths (32.9%) and 1196 deaths (34.8%), respectively (odds ratio, 1.02; 95% CI, 0.82-1.26; P =.88). Among 20 prespecified secondary outcomes not adjusted for multiple comparisons, 6 were significantly improved in the intervention group (use of low tidal volumes, avoidance of heavy sedation, use of central venous catheters, use of urinary catheters, perception of team work, and perception of patient safety climate), whereas there were no significant differences between the intervention group and the control group for 14 outcomes (ICU mortality, central line-associated bloodstream infection, ventilator-associated pneumonia, urinary tract infection, mean ventilator-free days, mean ICU length of stay, mean hospital length of stay, bed elevation to ≥30°, venous thromboembolism prophylaxis, diet administration, job satisfaction, stress reduction, perception of management, and perception of working conditions). CONCLUSIONS AND RELEVANCE: Among critically ill patients treated in ICUs in Brazil, implementation of a multifaceted quality improvement intervention with daily checklists, goal setting, and clinician prompting did not reduce in-hospital mortality. Research Institute HCor-Hospital do Coração, Rua Abílio Soares 250, 12th Floor Research Institute HCor-Hospital do Coração D'Or Institute for Research and Education Oswaldo Cruz Foundation Latin American Sepsis Institute Hospital Samaritano Hospital Moinhos de Vento University of Pittsburgh Casa de Saúde Santa Marta Casa de Saúde São Bento Centro Hospitalar Unimed Complexo Hospitalar São Mateus Fundação Hospital de Clinicas Gaspar Vianna Fundação Hospital Getúlio Vargas Hospital Aristides Maltez Hospital Aviccena Hospital Casa de Caridade de Carangola Hospital Casa de Portugal Hospital Copa D'Or Hospital da Sagrada Familia Hospital das Clinicas-FMUSP Hospital das Clinicas da UFPE Hospital das Clínicas Faculdade de Medicina de Botucatu/UNESP Hospital das Clinicas de Goiás Hospital das Clinicas Luzia de Pinho Melo-SPDM Hospital de Base do Distrito Federal Hospital de Clinicas de Porto Alegre Hospital de Messejana Dr Carlos Alberto Studart Gomes Hospital de Urgência e Emergência de Rio Branco Hospital Distrital Dr Evandro Ayres de Moura Hospital do Coração Balneário Camboriú Hospital e Pronto Socorro Dr Aristóteles Platao Bezerra de Araújo Hospital Eduardo de Menezes Hospital Estadual Américo Brasiliense Hospital Estadual Getúlio Vargas-Secretaria de Estado de Saúde Hospital Estadual Monsenhor Walfredo Gurgel Hospital Evangélico de Cachoeira de Itapemirim Hospital Federal da Lagoa Hospital Federal Servidores do Estado Hospital Fernandes Tavora Hospital Geral de Camaçari Hospital Geral de Fortaleza Hospital Geral de Nova Iguaçu Hospital Geral de Palmas Hospital Guilherme Álvaro Hospital Instituto Dr Jose Frota Hospital Joari Hospital Maternidade e Pronto Socorro Santa Lucia Hospital Maternidade Municipal Dr Odelmo Leão Carneiro Hospital Municipal Dr Carmino Caricchio Hospital Municipal de Paracatu Hospital Municipal Dr Mario Gatti Hospital Municipal Padre Germano Lauck de Foz do Iguaçu Hospital Municipal Pedro II Hospital Municipal Souza Aguiar Hospital Naval Marcilio Dias Hospital Nereu Ramos Hospital Nossa Senhora Auxiliadora Hospital Nossa Senhora dos Prazeres Hospital 9 de Julho Hospital Primavera Hospital Procordis Hospital Pronto Socorro 28 de Agosto Hospital Regional da Unimed Fortaleza Hospital Regional de Juazeiro Hospital Universitário Regional dos Campos Gerais Hospital Regional de Presidente Prudente Hospital Regional Deputado Manoel Gonçalves Abrantes Hospital Regional Público do Araguaia Hospital Regional João Penido Hospital Santa Casa de Campo Mourão Hospital Municipal Santa Isabel-Joao Pessoa Hospital Santa Lucia de Divinópolis Hospital Santa Rosa Hospital Municipal São Francisco de Assis Hospital São Joao de Deus Hospital São Jose-Criciúma Hospital São Jose de Doenças Infecciosas Hospital São Jose de Teresópolis Hospital São Jose do Avaí Hospital São Paulo Hospital São Vicente de Paula-Cruz Alta Hospital São Vicente de Paulo-Vitória da Conquista Hospital São Vicente de Paulo-Passo Fundo Hospital Unimed Bebedouro Hospital Unimed Costa do Sol Hospital Unimed Maceió Hospital Unimed Natal Hospital Unimed Rio Hospital Universitário-Universidade Estadual de Londrina Hospital Universitário Cassiano Antonio Moraes-Universidade Federal do Espirito Santo Hospital Universitário Lauro Wanderley Hospital Universitário Onofre Lopes Hospital Universitário Polydoro Ernani de São Thiago-Universidade Federal de Santa Catarina Hospital Universitário Prof. Edgar Santos-Universidade Federal da Bahia Hospital Universitário Regional de Maringá Hospital Universitário São Francisco de Paula-Pelotas Hospital Vila da Serra-Instituto Materno Infantil de Minas Gerais Hospital Vivalle Instituto Nacional de Infectologia Evandro Chagas/Fiocruz Irmandade da Santa Casa de Misericórdia de São Paulo Irmandade do Hospital Nossa Senhora das Dores Irmandade Santa Casa de Misericórdia de Maringá Santa Casa de Belo Horizonte Santa Casa de Caridade de Diamantina Santa Casa de Misericórdia de Anapolis Santa Casa de Misericórdia de Feira de Santana Santa Casa de Misericórdia de Guaxupé Santa Casa de Misericórdia de Pelotas Santa Casa de Misericórdia de Porto Alegre Santa Casa de Misericórdia de São Joao Del Rei Sociedade Beneficente Hospitalar Maravilha Unidade de Emergência Hospital das Clinicas de Ribeirão Preto-FMRP-USP Hospital de Clinicas-Universidade Estadual de Campinas Vila Velha Hospital Vitoria Apart Hospital Hospital das Clínicas Faculdade de Medicina de Botucatu/UNESP