1. Implementation of quality improvement (QI) interventions consisting of daily checklists, goal setting, and clinician prompting in Brazilian ICUs did not result in reduced in-hospital mortality.
2. Four care processes with poor baseline characteristics were modestly improved through the use of these QI interventions (use of low tidal volume, light sedation, use of central venous catheters, and use of urinary catheters).
Evidence Rating Level: 1 (Excellent)
Study Rundown: In the early 1900s the widespread implementation of a simple idea managed to change medicine forever. This idea—that doctors should wash their hands in order to prevent the transmission of disease—went on to save millions of lives over the years. Recently, many people have suggested the implementation of yet another straightforward idea in the hopes of reaping similar benefits. Checklists, the evidence has shown, can improve patient outcomes by ensuring that all critical steps in a care process are completed appropriately. These checklists and other similar QI interventions have shown their effectiveness in a number of settings in the developed world, but have yet to be thoroughly tested in low- and middle-income countries.
Thus, the authors of this study conducted a randomized clinical trial to determine the effectiveness of checklists, goal setting, and clinician prompts on in-hospital mortality in Brazilian adult ICUs. They found that the introduction of these changes did not decrease mortality or improve other clinical outcomes. While strengthened by its randomized design and large population, the study was weakened by a limited follow-up time that may have obscured the full effect of the interventions. Additionally, an analysis of the origins of safety problems in the ICUs was not conducted. Overall though, this study is one of the first of its kind and lays the groundwork for further research and continued care improvement in low- and middle-income countries.
In-Depth [randomized clinical trial]: This randomized clinical trial ran in two phases. Phase 1, the observational phase, classified the baseline characteristics of study sites, while Phase 2, the randomization phase, was conducted between April 2014 and November 2014, and tested whether QI interventions were associated with improvements in morbidity and mortality. A total of 13 638 patients in 118 ICUs were enrolled in the study with 6877 in Phase 1 and 6761 in Phase 2. In the randomized phase, there were 1096 in-hospital deaths among 3327 patients (32.9%) in the intervention group and 1196 deaths among 3434 patients (34.8%) in the control group (adjusted OR 1.02; 95%CI 0.82 to 1.26; p = 0.88). The QI intervention improved adherence for 4 care processes: increased use of low tidal volume (67.5% vs. 58.9% of patient-days; adjusted RR 1.14; 95%CI 1.03-1.26; p = 0.01), increased patient-days receiving light sedation or alert and calm among patients under mechanical ventilation (40.5% vs. 35.0% of patient-days; adjusted RR 1.19; 95%CI 1.00-1.42; p = 0.05), decreased use of central venous catheters (72.4% vs. 72.9% of patient-days; adjusted RR 0.90; 95%CI 0.83-0.98; p = 0.02) and decreased use of urinary catheters (62.8% vs. 74.8% of patient-days; adjusted RR 0.86; 95%CI 0.80-0.93; p < 0.001).
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