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A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care.

de Vos ML, van der Veer SN, Wouterse B, Graafmans WC, Peek N, de Keizer NF, Jager KJ, Westert GP, van der Voort PH - Implement Sci (2015)

Bottom Line: The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15).The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group).A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU.

View Article: PubMed Central - PubMed

Affiliation: Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, PO Box 90153, , 5000 LE, Tilburg, The Netherlands. mdevos@amphia.nl.

ABSTRACT

Background: Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards.

Methods: In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs.

Results: We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group).

Conclusions: A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up.

Isrctn: ISRCTN50542146.

No MeSH data available.


Related in: MedlinePlus

Elements of the multifaceted feedback intervention (InFoQI program) and the quarterly standard feedback reports in the control group
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Fig1: Elements of the multifaceted feedback intervention (InFoQI program) and the quarterly standard feedback reports in the control group

Mentions: The intervention strategy was an improved NICE feedback reports containing data on 11 indicators. These feedback reports were extended by incorporating the results of a barrier analysis of NICE participants and systematic literature reviews [13, 14, 22]. One of the identified barriers showed a lack of confidence in data quality of the feedback reports. In addition, difficulties in the interpretation of the feedback report hampered quality improvement (QI) activities [22, 23]. The systematic reviews suggested that feedback might be more effective when provided at least monthly in both written and verbal form, when it is combined with the development of a QI plan, and when the feedback has an educational component [13, 23]. Based on this analysis, each intervention ICU during 1 year (1) received monthly and quarterly feedback reports, including information on adherence to the two organizational standards, (2) established a multidisciplinary QI team, (3) received two educational outreach visits. Figure 1 (left side) graphically displays the intervention; a detailed description was published elsewhere [24]. The intervention did not provide explicit tools for professionals to improve bed occupancy rate or nurse-to-patient ratio. The monthly report focused on the ICUs’ own adherence to the standards over time. For example, run charts with occupancy rates per nursing shift three times daily were provided with the 80 % standard visualized as a red horizontal line. The extensive quarterly report focused mainly on comparing an ICU’s adherence level with a benchmark, which was the average adherence level of a group of comparable ICUs. For example, box plots summarizing the nurse-to-patient ratio per week for an individual ICU compared to other ICUs with a similar volume of admitted patients with the guideline-based standard of 0.5 are clearly projected. The monthly reports and the extensive quarterly benchmark reports also contained information on four other clinical indicators next to the two organizational indicators. For the remaining five indicators of the set of 11, no intervention was defined. In each intervention ICU, a multidisciplinary QI team was formed with at least one intensivist, one nurse, and a representative of the ICU management. They had to be available for a minimum of 4 h per month to perform study activities. We suggested adding a data manager as an additional member of the QI team. The teams’ main tasks were to discuss the feedback in a monthly meeting, to formulate a local QI action plan, to initiate and evaluate QI activities, and to share the results with their colleagues. Finally, each ICU in the intervention group received two educational outreach visits by two study investigators (MV and SV). The visits aimed to increase the confidence in data quality, to facilitate correct interpretation of data that was presented in the feedback reports, to translate these data into QI initiatives, and to identify opportunities for improvement.Fig. 1


A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care.

de Vos ML, van der Veer SN, Wouterse B, Graafmans WC, Peek N, de Keizer NF, Jager KJ, Westert GP, van der Voort PH - Implement Sci (2015)

Elements of the multifaceted feedback intervention (InFoQI program) and the quarterly standard feedback reports in the control group
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4495635&req=5

Fig1: Elements of the multifaceted feedback intervention (InFoQI program) and the quarterly standard feedback reports in the control group
Mentions: The intervention strategy was an improved NICE feedback reports containing data on 11 indicators. These feedback reports were extended by incorporating the results of a barrier analysis of NICE participants and systematic literature reviews [13, 14, 22]. One of the identified barriers showed a lack of confidence in data quality of the feedback reports. In addition, difficulties in the interpretation of the feedback report hampered quality improvement (QI) activities [22, 23]. The systematic reviews suggested that feedback might be more effective when provided at least monthly in both written and verbal form, when it is combined with the development of a QI plan, and when the feedback has an educational component [13, 23]. Based on this analysis, each intervention ICU during 1 year (1) received monthly and quarterly feedback reports, including information on adherence to the two organizational standards, (2) established a multidisciplinary QI team, (3) received two educational outreach visits. Figure 1 (left side) graphically displays the intervention; a detailed description was published elsewhere [24]. The intervention did not provide explicit tools for professionals to improve bed occupancy rate or nurse-to-patient ratio. The monthly report focused on the ICUs’ own adherence to the standards over time. For example, run charts with occupancy rates per nursing shift three times daily were provided with the 80 % standard visualized as a red horizontal line. The extensive quarterly report focused mainly on comparing an ICU’s adherence level with a benchmark, which was the average adherence level of a group of comparable ICUs. For example, box plots summarizing the nurse-to-patient ratio per week for an individual ICU compared to other ICUs with a similar volume of admitted patients with the guideline-based standard of 0.5 are clearly projected. The monthly reports and the extensive quarterly benchmark reports also contained information on four other clinical indicators next to the two organizational indicators. For the remaining five indicators of the set of 11, no intervention was defined. In each intervention ICU, a multidisciplinary QI team was formed with at least one intensivist, one nurse, and a representative of the ICU management. They had to be available for a minimum of 4 h per month to perform study activities. We suggested adding a data manager as an additional member of the QI team. The teams’ main tasks were to discuss the feedback in a monthly meeting, to formulate a local QI action plan, to initiate and evaluate QI activities, and to share the results with their colleagues. Finally, each ICU in the intervention group received two educational outreach visits by two study investigators (MV and SV). The visits aimed to increase the confidence in data quality, to facilitate correct interpretation of data that was presented in the feedback reports, to translate these data into QI initiatives, and to identify opportunities for improvement.Fig. 1

Bottom Line: The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15).The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group).A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU.

View Article: PubMed Central - PubMed

Affiliation: Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, PO Box 90153, , 5000 LE, Tilburg, The Netherlands. mdevos@amphia.nl.

ABSTRACT

Background: Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards.

Methods: In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs.

Results: We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group).

Conclusions: A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up.

Isrctn: ISRCTN50542146.

No MeSH data available.


Related in: MedlinePlus