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JAMA. 2016 Apr 12;315(14):1480-90. doi: 10.1001/jama.2016.3463.

Effect of a Quality Improvement Intervention With Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients: A Randomized Clinical Trial.

Collaborators (350)

Cavalcanti AB, Augusto Bozza F, Machado FR, Salluh JI, Campagnucci VP, Vendramim P, Guimaraes HP, Normilio-Silva K, Damiani LP, Romano E, Carrara F, de Souza JL, Silva AR, Ramos GV, Teixeira C, Silva NB, Chang CC, Angus DC, Berwanger O, Neto PA, Fernandes CA, Luchesi CÁ, de Sa NR, Faria Rodrigues RA, Radespiel LS, Iorio VL, Bhering D, Linhares VR, Adrieno Westphal G, Sperotto G, da Silva Rossi SB, Ferreira TE, de Brito Sobrinho E, Reis HJ, Carneiro MS, de Oliveira Lameira A, Fernandes JF, Ferreira RL, Pinho SC, Dultra L, Hizumi LO, de Lima NF, da Silva AR, Santos Ld, Vaz SM, Oliveira JM, Laviola MB, de Freitas WV, Passos L, Rabello LS, de Siqueira CR, de Oliveira Silva LC, Barreto FF Jr, Cruz EM, Sa Malbouisson LM, Caltabeloti FP, Bassi E, da Silva PR, Cadamuro F, dos Santos Cagnon RG, Ho YL, Neto LC, Randi BA, de Godoy MM, Sobral PD, de Barros Campelo E Jr, de Stefano LM, Gut AL, de Stefano GM, Ferreira DM, Gonçalves FA, Alves FR, Filho WN, Marchetti RO, Sa S, Anabuki NT, Vieira SR, Parolo E, Prado K, Lisboa NG, Fortaleza SC, Porfirio ML, Colares MM, da Silva RS, Vasconcelos M, de Souza F, de Moura EA, de Figueiredo LM, Seabra NP, de Oliveira PC, Martins MA, Muller RB, Recalcatti MC, de Araújo AP, Fernandes Camurça Martins RH, de França LE, de Carvalho FB, Moreira GC, Cechinatti ED, Passos AC, da Costa Ferreira M, Rodrigues AC, dos Santos Begni V, Jardim AM, Maciel AC, Thompson MM, Pinheiro EP, Gonçalves CH, Rosenfeld RS, Rosenfeld VA, Japiassú L, de Oliveira Bissoli MI, da Costa Tavares R, Gonçalves MR, Martins LF, Oliveira MH, Ferreira AK, Jorge Santos Lima E, de Almeida Oliveira T, Campos MT, de Freitas NA, da Silva S, Ferreira VL, de Oliveira Sodré A, Villela CL, Medeiros ED, de Souza Junior NJ, de Souza Monteiro R, Ribeiro AS, Giovanini CC, Carvalho ET, Fernandes LC, Rocha DM, de Freitas CM, de Magalhaes Menezes MA, Stancato RI, Faria GB, Asturi G, Bergo RR, Dall'Orto FT, Ribeiro GR, dos Santos Toneto MA, Teixeira C, dos Santos MA, Maccari JG, Górios ST, de Morais JP, Zambelli DM, de Souza RM, de Paiva EC, Ribeiro AG, Pereira MV, Nascimento L, da Silva R, de Almeida R, Couto KA, Toffolo IM, da Rocha Paranhos JE, Paixão Fraga AR, Aguiar S, de Oliveira AA Jr, Lannes R, da Silva Gomes Ludovico A, Carvalho LF, de Araújo Campos L, Soboslai P, Maia IS, Rassele T, Zanzi C, Martins Michel VN, Gonçalves SP, de Oliveira Gargioni RR, Duarte RZ, Dias MD, Diziola AD, da Silva DV, Hagihara MS, de Oliveira AL, Reis DL, Feijó J, Oliveira MA, de Souza LV, de Oliveira Cavalcante L, Rodrigues J, de Pinho MC, Maia MA, Lima VF, Nogueira EM, Gomes AC, de Oliveira KR, Bandeira JA, Mesquita CC, Arcaro G, Wolff C, Filho DC, Betonico GN, Maroto RP, Menegon LF, Henrique da Silveira P Jr, de Queiroga Oliveira GE, da Silva Lima WM, Nunes LB, Martins Neto SG, de Oliveira Lopes LK, de Mendonça Lima MA, Milagres LM, Gribel D'Ávila V, Schiavetto M, dos Santos PA, de Matos Raimundo F, de Melo CL, de Carvalho AA, de Santana CF, Fonseca AL, da Silva MA, Nasrala ML, Pinheiro EK, Pereira Santos MR, da Silva GA, Silva GA, Moreira R, Sebold ML, da Rocha ML, Ribeiro Leão MA, de Assis J, Pizzol FD, Tomasi CD, da Silva JN, Fragoso LV, Araújo Silva Nepomuceno Barros D, Coutinho MM, Pereira RS, dos Santos VO, Macedo SK, de Souza Bouzaga Fulani D, Aglio ES Jr, de Góis AF, Teixeira K, Ping PZ, Nazario Viecili PR, de Almeida SD, Moreno Santos G Jr, Segundo DN, Santana MX, Calvete JO, Renner L, Trindade Francisco VV, de Carvalho DS, da Silva Batista Campos AN, Fernandes Curvelo SL Jr, de Oliveira NR, de Paula Freitas Deborssan S, dos Anjos Silva Guimaraes MR, Bastos LC, Gomes LM, de Lima Vale E, da Silva DA, Gomes RV, Mattos MA, Nogueira PM, Nascimento VC, Grion CM, Oliveira Dias A, de Souza Omori Maier G, Vassallo PF, Souza de Lima MH, dos Reis WL, Loureiro WL, Borghardt AT, Mendes CL, Gottardo PC, Ramalho Neto JM, da Silva EP, da Silva Aragao MG, de Lima EM, de Souza RL, Takashiba KS, Gusmão-Flores D, Araújo TL, Mota RS, Germano A, Antunes F, Bin Silva SR, Osório Guerreiro M, Bainy MP, de Azevedo Duarte Hardt P, de Andrade Urbano HC, de Souza CA, Mangini C, da Silva Ramos FJ, de Araújo LP, Japiassú AM, Medeiros DM, da Silva MF, Hirata F, Marco R, Peixoto E, Esmeraldo ML, Damásio Pereira LA, Carvalho Leal R, Aranha Torres PR, Torres MM, de Belo Horizonte SC, de Moura MR, de Oliveira CD, Gonçalves Moreira AS, Silva Ferreira BE, dos Santos Cruz CL, Soares PM, Correia PC, Silva Almeida LL, de Caridade de Diamantina SC, Sousa MF, Antonio Santiago Vial A, Ferreira Souza MM, Quintana D, Guimaraes AC, Menezes Diniz MD, Panelli Ferreira PH, Rios Santana Cordeiro RM, da Cunha Mendes MO, Oliveira de Lima S, Bezerra SA, dos Reis da Silva AB, Batista CC, Neumann T, Leite RO, Lisboa TC, Hädrich M, Rodrigues Filho EM, da Rocha Paranhos JL, Nascimento dos Santos CH, de Souza HC, Toribio Cuadra JL, de Souza RV, Cuadra JL, Spanholi J, de Carvalho Borges M, Lovato WJ, Mara Gomes T, MauroWitzel Machado LA, Santos TM, de Carvalho Filho MA, Garcia Bernardes KA, Pereira Santos JR, Mautoni Queiroga Liparizi AE, Venturim Lana P, Piras C, Virgílio Nespoli L, Silva Taliule A.

Author information

1
Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.
2
D'Or Institute for Research and Education, Rio de Janeiro, Brazil3Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
3
Latin American Sepsis Institute, São Paulo, Brazil.
4
D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
5
Hospital Samaritano, São Paulo, Brazil.
6
Hospital Moinhos de Vento, Porto Alegre, Brazil.
7
University of Pittsburgh, Pittsburgh, Pennsylvania.
8
University of Pittsburgh, Pittsburgh, Pennsylvania8Associate Editor, JAMA.

Abstract

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 prompting for 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.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT01785966.

PMID:
27115264
DOI:
10.1001/jama.2016.3463
[Indexed for MEDLINE]

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