Implementation
of a multifaceted quality improvement intervention with daily checklists, goal
setting, and clinician prompting did not reduce in-hospital mortality compared
with routine care among critically ill patients treated in intensive care units
(ICUs) in Brazil, according to a study appearing in the April 12 issue of JAMA.
Checklists
have been proposed as tools to ensure that essential components of care are not
omitted. In ICUs, the use of checklists is associated with increased adherence
to guidelines, reduced rates of central line-associated bloodstream infection,
and earlier extubation. Using checklists combined with daily goals assessment
and clinician prompting may improve communication, adherence to care processes,
and clinical outcomes. However, evidence from
randomized trials supporting the use of checklists in critical care is lacking.
Alexandre
B. Cavalcanti, M.D., Ph.D., of the HCor-Hospital do Coracao, Sao Paulo, Brazil
and colleagues conducted a study that had two phases. Phase 1 was an
observational study to assess baseline data on work climate, care processes,
and clinical outcomes in 118 Brazilian ICUs. In phase 2, the same ICUs were randomized
to a quality improvement intervention, including a daily checklist and goal
setting during multidisciplinary rounds with follow-up clinician
prompting for 11 care processes, or to routine care. The first 60 admissions of
longer than 48 hours per ICU were enrolled in each phase.
A
total of 6,877 patients (average age, 60 years) were enrolled in the baseline
(observational) phase and 6,761 (average age, 60 years) in the randomized
phase, with 3,327 patients enrolled in ICUs (n = 59) assigned to the
intervention group and 3,434 patients in ICUs (n = 59) assigned to routine
care. The researchers found that there was no significant difference in
in-hospital mortality between the intervention group and the usual care group,
with 1,096 deaths (33 percent) and 1,196 deaths (35 percent), respectively.
Potential
improvements were observed in 4 of 7 care processes and 2 safety climate
domains, although except for 1 outcome, urinary catheter use, these findings
were not significant after adjustment for multiple comparisons.
The
authors write that potential explanations for the lack of effect on mortality
found in this study include that the intervention needs time to work and the
observation period was too short, or that the items on the checklist have very
modest or negligible effects on mortality.
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