A disciplined approach to implementation of evidence-based practices decreases ICU and hospital length of stay in traumatically injured patients

Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review

OBJECTIVE

To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).

BACKGROUND

At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines.

METHODS

A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0.

RESULTS

Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report.

CONCLUSIONS

Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.

A clinical librarian in a hospital critical care unit may generate a positive return on investment

BACKGROUND

Timely information provided by clinical librarians can contribute to outcomes such as improved patient care and time savings for hospital staff. What is unknown is the return on investment (ROI) of a clinical librarian on a critical care unit.

OBJECTIVE

The aim of this study was to assess the ROI, from the employer perspective, of placing a clinical librarian in a critical care unit in a large UK acute hospital.

METHODS

Using a mixed methods approach, ROI was estimated by comparing the total costs with the total monetised benefits of implementing the clinical librarian intervention. Total costs included salary and equipment costs. Total monetised benefits included time saving for hospital staff, support for professional development and improved patient care.

RESULTS

When total monetised benefits were compared with total costs, the 15-month clinical librarian intervention generated a positive ROI of £1.18-£3.03 for every £1 invested.

DISCUSSION

Using outcome measures derived from previous research, this novel study generated promising results indicative for commissioners seeking to improve patient care and deliver value for money. To improve generalisability, multisite studies using standardised ROI tools are recommended.

CONCLUSION

Employing a clinical librarian in a critical care unit can generate a positive ROI.

Health care workers in Africa access a broad range of topics using evidence-based online medical information

Health care workers (HCW) rely on Internet-based medical resources to obtain current evidence-based clinical guidelines. While such resources are being used with increasing frequency in developed countries, they have not been broadly employed in resource-limited settings (RLS). To investigate the feasibility and the types of medical content used by HCW in RLS, we studied one Internet-based medical resource used in the United States, (UpToDate©) in four hospitals in Africa. Health care workers were trained on how to use this resource and surveyed over a six month study period. Automated topic tracking found that HCW searched a variety of medical topics. About 78% of HCW reported daily or weekly use of the Internet-based medical resource and 70% felt the tool was very useful for teaching. All users report the tool increased their clinical knowledge. This descriptive study suggests that Internet-based medical information resources are feasible in RLS and are accessed for a broad variety of medical topics. Supplemental content providing guidance when minimal diagnostic and therapeutic options exist could increase its relevance in RLS. With increased availability, Internet-based medical information could enhance current global health care initiatives to improve providers' knowledge, clinical practice and potentially patient outcomes.

Application of the principles of evidence-based medicine to patient care

Evidence-based medicine (EBM) is the conscientious and judicious use of the best evidence available collected from clinical trials, guidelines, and consensus statements. This article provides simple ways to practice EBM using five steps (assess the patient, ask a clearly focused clinical question, acquire the best evidence available from the medical literature, appraise the evidence, and apply the evidence to patient care) and how to execute each step properly, multiple examples of how to apply EBM to patient care, and examples of how to apply the PICO mnemonic (patient, intervention, comparison, and outcome) to the process of EBM.

Critical Illness Outcome Study: An Observational Study on Protocols and Mortality in Intensive Care Units

INTRODUCTION

Many individual Intensive Care Unit (ICU) characteristics have been associated with patient outcomes, including staffing, expertise, continuity and team structure. Separately, many aspects of clinical care in ICUs have been operationalized through the development of complex treatment protocols. The United State Critical Illness and Injury Trials Group-Critical Illness Outcomes Study (USCIITG-CIOS) was designed to determine whether the extent of protocol availability and use in ICUs is associated with hospital survival in a large cohort of United States ICUs. Here, we describe the study protocol and analysis plan approved by the USCIITG-CIOS Steering Committee.

METHODS

USCIITG-CIOS is a prospective, observational, ecological multi-centered "cohort" study of mixed ICUs in the U.S. The data collected include organizational information for the ICU (e.g., protocol availability and utilization, multi-disciplinary staffing assessment) and patient level information (e.g. demographics, acute and chronic medical conditions). The primary outcome is all-cause hospital mortality, with the objective being to determine whether there is an association between protocol number and hospital mortality for ICU patients. USCIITG-CIOS is powered to detect a 3% difference in crude hospital mortality between high and low protocol use ICUs, dichotomized according to protocol number at the median. The analysis will utilize regression modeling to adjust for outcome clustering by ICU, with secondary linear analysis of protocol number and mortality and a variety of a priori planned ancillary studies. There are presently 60 ICUs participating in USCIITG-CIOS to enroll approximately 6,000 study subjects.

CONCLUSIONS

USCIITG-CIOS is a large multicentric study examining the effect of ICU protocol use on patient outcomes. The primary results of this study will inform our understanding of the relationship between protocol availability, use, and patient outcomes in the ICU. Moreover, given the shortage of intensivists worldwide, the results of USCIITG-CIOS can be used to promote more effective ICU and care team design and will impact the delivery of intensive care services beyond individual practitioners.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01109719.