A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units: A Cluster Randomized Trial

Study Questions:

Can a multicenter quality improvement program increase delivery of evidence-based intensive care unit (ICU) practices?


The authors performed a cluster-randomized trial at 15 community hospital ICUs in Ontario, Canada. A videoconference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms were used to sequentially improve delivery of six practices (prevention of ventilator associated pneumonia, prophylaxis against deep vein thrombosis, prevention of blood stream infections, early enteral feeding, decubitus ulcer prevention, and daily spontaneous breathing trials). ICUs were randomized into two groups with each group receiving a specific intervention, targeting a new practice every 4 months, while acting as control for the other group, in which a different practice was targeted during the same period.


The intervention arm had greater adoption of the targeted practices (odds ratio [OR], 2.79; 95% confidence interval [CI], 1.00-7.74). The most improvement was seen in use of semirecumbent positioning to prevent ventilator-associated pneumonia (90.0% of patient-days in last month vs. 50.0% in first month; OR, 6.35; 95% CI, 1.85-21.79) and precautions to prevent catheter-related bloodstream infection (70.0% of patients receiving central lines vs. 10.6%; OR, 30.06; 95% CI, 11.00-82.17). Little change was noted in adoption of other practices such as prophylaxis for deep vein thrombosis and early enteral feeding, but this may have been related to high baseline adherence.


The authors concluded that dedicated quality improvement projects can translate into improved adoption of evidence-based ICU practices.


This study demonstrates the power of quality improvement efforts to enhance uptake of evidence-based practice across multiple institutions. The improvement was greatest at sites that were performing poorly, suggesting that these efforts may be more effective if specifically targeted at underperforming sites and focused on specific deficiencies in the care process.

Clinical Topics: Vascular Medicine

Keywords: Pneumonia, Ventilator-Associated, Quality Improvement, Intensive Care Units, Central Venous Catheters, Pressure Ulcer, Canada, Hospitals, Community, Ontario, Venous Thrombosis, Feedback, Catheter-Related Infections, Enteral Nutrition

< Back to Listings