Quality improvement projects targeting health care-associated infections: comparing Virtual Collaborative and Toolkit approaches.

BACKGROUND: Collaborative and toolkit approaches have gained traction for improving quality in health care. OBJECTIVE: To determine if a quality improvement virtual collaborative intervention would perform better than a toolkit-only approach at preventing central line-associated bloodstream infections (CLABSIs) and ventilator-associated pneumonias (VAPs). DESIGN AND SETTING: Cluster randomized trial with the Intensive Care Units (ICUs) of 60 hospitals assigned to the Toolkit (n=29) or Virtual Collaborative (n=31) group from January 2006 through September 2007. MEASUREMENT: CLABSI and VAP rates. Follow-up survey on improvement interventions, toolkit utilization, and strategies for implementing improvement. RESULTS: A total of 83% of the Collaborative ICUs implemented all CLABSI interventions compared to 64% of those in the Toolkit group (P = 0.13), implemented daily catheter reviews more often (P = 0.04), and began this intervention sooner (P < 0.01). Eighty-six percent of the Collaborative group implemented the VAP bundle compared to 64% of the Toolkit group (P = 0.06). The CLABSI rate was 2.42 infections per 1000 catheter days at baseline and 2.73 at 18 months (P = 0.59). The VAP rate was 3.97 per 1000 ventilator days at baseline and 4.61 at 18 months (P = 0.50). Neither group improved outcomes over time; there was no differential performance between the 2 groups for either CLABSI rates (P = 0.71) or VAP rates (P = 0.80). CONCLUSION: The intensive collaborative approach outpaced the simpler toolkit approach in changing processes of care, but neither approach improved outcomes. Incorporating quality improvement methods, such as ICU checklists, into routine care processes is complex, highly context-dependent, and may take longer than 18 months to achieve.

Measuring and comparing safety climate in intensive care units.

BACKGROUND: Learning about the factors that influence safety climate and improving the methods for assessing relative performance among hospital or units would improve decision-making for clinical improvement. OBJECTIVES: To measure safety climate in intensive care units (ICU) owned by a large for-profit integrated health delivery systems; identify specific provider, ICU, and hospital factors that influence safety climate; and improve the reporting of safety climate data for comparison and benchmarking. RESEARCH DESIGN: We administered the Safety Attitudes Questionnaire (SAQ) to clinicians, staff, and administrators in 110 ICUs from 61 hospitals. SUBJECTS: A total of 1502 surveys (43% response) from physicians, nurses, respiratory therapists, pharmacists, mangers, and other ancillary providers. MEASURES: The survey measured safety climate across 6 domains: teamwork climate; safety climate; perceptions of management; job satisfaction; working conditions; and stress recognition. Percentage of positive scores, mean scores, unadjusted random effects, and covariate-adjusted random effect were used to rank ICU performance. RESULTS: The cohort was characterized by a positive safety climate. Respondents scored perceptions of management and working conditions significantly lower than the other domains of safety climate. Respondent job type was significantly associated with safety climate and domain scores. There was modest agreement between ranking methodologies using raw scores and random effects. CONCLUSIONS: The relative proportion of job type must be considered before comparing safety climate results across organizational units. Ranking methodologies based on raw scores and random effects are viable for feedback reports. The use of covariate-adjusted random effects is recommended for hospital decision-making.

Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals.

OBJECTIVE: A 2001 survey found that most healthcare professionals considered intensive care unit (ICU) delirium as a serious problem, but only 16% used a validated delirium screening tool. Our objective was to assess beliefs and practices regarding ICU delirium and sedation management. DESIGN AND SETTING: Between October 2006 and May 2007, a survey was distributed to ICU practitioners in 41 North American hospitals, seven international critical care meetings and courses, and the American Thoracic Society e-mail database. STUDY PARTICIPANTS: A convenience sample of 1384 healthcare professionals including 970 physicians, 322 nurses, 23 respiratory care practitioners, 26 pharmacists, 18 nurse practitioners and physicians' assistants, and 25 others. RESULTS: A majority [59% (766 of 1300)] estimated that more than one in four adult mechanically ventilated patients experience delirium. More than half [59% (774 of 1302)] screen for delirium, with 33% of those respondents (258 of 774) using a specific screening tool. A majority of respondents use a sedation protocol, but 29% (396 of 1355) still do not. A majority (76%, 990 of 1309) has a written policy on spontaneous awakening trials (SATs), but the minority of respondents (44%, 446 of 1019) practice spontaneous awakening trials on more than half of ICU days. CONCLUSIONS: Delirium is considered a serious problem by a majority of healthcare professionals, and the percent of practitioners using a specific screening tool has increased since the last published survey data. Although most respondents have adopted specific sedation protocols and have an approved approach to stopping sedation daily, few report even modest compliance with daily cessation of sedation.

Survey of infection control programs in a large national healthcare system.

In light of consumers' and regulators' increasing focus on infection prevention, infection control practices and resources were surveyed at 134 hospitals owned by the Hospital Corporation of America. Infection control practices and resources varied substantially among hospitals, and many facilities reported difficulty acquiring the data they needed to report infection rates.