Objectives: Evidence-based practices are not consistently applied in the ICU. We sought to determine if nurse-led remote screening and prompting for evidence-based practices using an electronic health record could impact ICU care delivery and outcomes in an academic medical center.
Design: Single-center, before-after evaluation of a quality improvement project.
Setting: Urban, academic medical center in the mid-Atlantic United States with eight subspecialty ICUs and 156 ICU beds.
Patients: Adult patients admitted to the ICU between January 1, 2011, and August 31, 2012.
Interventions: Beginning on July 25, 2011, trained ICU nurses screened all ICU patients for selected evidence-based practices on a daily basis. The screening was conducted from a remote office, facilitated by the electronic health record. Selected practices included compliance with a ventilator care bundle, assessment of appropriateness of indwelling venous and urinary catheters, and concordance between sedation orders and documented level of sedation. When gaps were observed, they were communicated to the point-of-care bedside nurse via telephone, page, or facsimile.
Measurements and Main Results: Fourteen thousand eight hundred twenty-three unique patients were admitted during the study period. We excluded 1,546 patients during a 2-month run-in period from July 1, 2011, to August 31, 2011, resulting in 4,339 patients in the 6-month preintervention period and 8,938 patients in the 12-month postintervention period. Compared with patients admitted in the preintervention period, patients admitted in the postintervention period were more likely to receive sedation interruption (incidence rate ratio, 1.57; 95% CI, 1.45–1.71) and a spontaneous breathing trial (incidence rate ratio, 1.24; 95% CI, 1.20–1.29). Hospital-acquired infection rates were not different between the two periods. Adjusting for patient characteristics and illness severity, patients in the postintervention period experienced shorter duration of mechanical ventilation (adjusted reduction, 0.61 d; 95% CI, 0.27–0.96; p < 0.001), shorter ICU length of stay (adjusted reduction, 0.22 d; 95% CI, 0.04–0.41; p = 0.02), and shorter hospital length of stay (adjusted reduction, 0.55 d; 95% CI, 0.15–0.93; p = 0.006). In-hospital mortality was unchanged (adjusted odds ratio, 0.96; 95% CI, 0.84–1.09; p = 0.54). The results were robust to tests for concurrent temporal trends and coincident interventions.
Conclusions: A program by which nurses screened ICU patients for best practices from a remote location was associated with improvements in the quality of care and reductions in duration of mechanical ventilation and length of stay, but had no impact on mortality.
1Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA.
2Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
3University of Pittsburgh Medical Center, Pittsburgh, PA.
4Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA.
* See also p. 996.
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Dr. Kahn consulted for the U.S. Department of Veterans Affairs. Dr. Kahn’s institution received grant support from the U.S. Department of Health and Human Services. Dr. Kahn has pending and active grants from the National Institutes of Health and the Health Resources and Services Administration on the topic of ICU telemedicine. Dr. Gunn consulted for ICU Medical and Nestle Nutrition, and served as an independent consultant for MedMal. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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