Background
Methods
Study design and participating centres
Hospital 1 | Hospital 2 | |
---|---|---|
No. of hospital beds | 250 | 350 |
Teaching hospital | ||
Undergraduate | Yes | Yes |
Resident physician | No | Yes |
No. of ICU beds | ||
Total at the centre | 16 | 30 |
ICU participating in study | 16 | 14 |
Computerized ICU | Yes | Yes |
Active protocol for: | ||
Sedation and analgesia | No | Yes |
Weaning | No | Yes |
Enteral nutrition | Yes | Yes |
Monitoring and MV alarms | No | No |
Register of AE | No | No |
Voluntary reporting of AE | Yes | Yes |
ENVIN-ICU participation (BZ, NZ, RZ) | Yes | Yes |
Other checklist systems (Not AASTRE) | Prevention of VAP, CRB | Prevention of VAP, CRB, intrahospital transfer |
Patient types | Medical | Medical, surgical, trauma |
Surgical | ||
Trauma | ||
Coronary |
Methodology for the implementation of the AASTRE
Design and description of the checklist
Role and training of prompters
Safety audits
Definition of variables and indicators
-
Perception of safety culture (in Hospital 2): We used a previously validated questionnaire [12] based on the Safety Climate Survey (SCS) and the Safety Attitude Questionnaire-ICU model (SAQ-ICU). It analysed six dimensions: teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition. The questionnaire on the perception of safety culture was administered to medical, nursing and ancillary staff. Three evaluation periods were considered: 1) initial period: the month prior to the start of the study; 2) intermediate period: month 6 of the study; 3) final period: the month after the end of the study.
-
The execution or updating of protocols and/or procedures promoted by the AASTRE was investigated.
-
The proportion of changes in the care process carried out as a result of verification was considered. IPR-AASTRE (improvement proportion related to the AASTRE) were calculated globally (IPR-AASTRE-G), for each safety measure (IPR-AASTRE), and for each block of variables (IPR-AASTRE-B), according to the following formulas:$$ {\text{IPR}} - {\text{AASTRE}} = \frac{{{\text{number of occasions on which the AASTRE changed clinical practice }}\left( {\text{{"yes}}, {\text{after the AASTRE"}}} \right)}}{{{\text{number of occasions on which the measure was selected }} - {\text{number of occasions on which the measure was not applicable}}}} \times 100 $$IPR-AASTRE-B helped simplify the assessment of the impact of other variables on utility. These variables are: type of patient (medical, surgical, neurocritical and trauma), staffing ratio [PNR; patient:nurse ratio (≤2:1 vs. >2:1) and PPR; patient:physician ratio (≤2:1, 2–3:1, >3:1)], the Sequential Organ Failure Assessment (SOFA) score and length of stay (length of stay at the time of safety audits (<7, 7–14, >14 days).$$ {\text{IPR}} - {\text{AASTRE}} - {\text{B}} = \frac{\text{sum of the number of occasions on which the AASTRE changed clinical practice in each block}}{{{\text{number of occasions on which the measure was selected in each block}} - {\text{number of occasions on which the measure was not applicable in each block}}}} \times 100 $$
-
The impact by the AASTRE on ICU mortality, average stay and rates of central venous catheter-related bacteraemia (CRB) and ventilator-associated pneumonia (VAP) using standardized definitions [13, 14] was investigated. The clinical definition of VAP requires patients to fulfil one radiographic, one systemic, and two pulmonary criteria. Radiographic criteria include new or progressive infiltrates, consolidation and cavitation. Systemic criteria include fever, abnormal white blood cell count and altered mental status. Pulmonary criteria include purulent sputum, new or worsening cough or dyspnoea or tachypnea, rales or bronchial breath sounds, and worsening gas exchange. CRB is defined in a patient with a central venous catheter with at least one positive blood culture (two blood culture if common skin contaminant organism) obtained from a peripheral vein, clinical manifestations of infections (i.e. fever, chills and/or hypotension), and no apparent source for the bloodstream infection except the catheter. One of the following should be present: a positive semi-quantitative (>15 CFU per catheter segment) or quantitative (>102 CFU per catheter segment) catheter culture, whereby the same organism (species) is isolated from a catheter segment and a peripheral blood culture; simultaneous quantitative blood cultures with a ratio of >3:1 CFU/ml of blood (catheter vs. peripheral blood); differential time to positivity (growth in a culture of blood obtained through a catheter hub is detected by an automated blood culture system at least 2 h earlier than a culture of simultaneously drawn peripheral blood of equal volume). The information relative to VAP and CRB was collected prospectively at both centres participating in the study and the previous year, using identical diagnostic criteria.
Statistical analysis
Results
Global | Hospital 1 | Hospital 2 |
p
| ||||
---|---|---|---|---|---|---|---|
N
| % |
N
| % |
N
| % | ||
Patient type | <0.0001 | ||||||
Medical | 570 | 47.0 | 242 | 57.6 | 328 | 41.3 | |
Neurosurgery | 118 | 9.7 | 12 | 2.9 | 106 | 13.4 | |
Surgical | 397 | 32.7 | 146 | 34.8 | 251 | 31.6 | |
Traumatic | 129 | 10.6 | 20 | 4.7 | 109 | 13.7 | |
PNR | <0.0001 | ||||||
≤ 2:1 | 787 | 64.8 | 16 | 3.8 | 771 | 97.1 | |
>2:1 | 427 | 35.2 | 404 | 96.2 | 23 | 2.9 | |
PPR | <0.0001 | ||||||
≤2:1 | 143 | 11.8 | 29 | 6.9 | 114 | 14.4 | |
2–3:1 | 756 | 62.3 | 240 | 57.1 | 516 | 65.0 | |
>3:1 | 315 | 25.9 | 151 | 36.0 | 164 | 20.6 | |
SOFA | 0.001 | ||||||
<4 | 723 | 59.6 | 282 | 67.1 | 441 | 55.6 | |
4–7 | 357 | 29.3 | 97 | 23.1 | 260 | 32.7 | |
8–12 | 110 | 9.1 | 31 | 7.4 | 79 | 9.9 | |
≥12 | 24 | 2.0 | 10 | 2.4 | 14 | 1.8 | |
Length of stay | <0.0001 | ||||||
<7 | 532 | 43.8 | 227 | 54.0 | 305 | 38.4 | |
7–14 | 237 | 19.5 | 62 | 14.8 | 175 | 22.0 | |
14–21 | 146 | 12.0 | 29 | 6.9 | 117 | 14.8 | |
≥21 | 299 | 24.7 | 102 | 24.3 | 197 | 24.8 |
Structure indicators
Dimensions | Start of study
N = 67 Positive responses, % | Intermediate period
N = 46 Positive responses, % | End period
N = 48 Positive responses, % |
p
|
---|---|---|---|---|
Atmosphere in place of work | 74.5 | 67.4 | 73.4 | NS |
Relations with colleagues | 64.2 | 59.8 | 60.9 | NS |
Organization and management of the service and the hospital | 40.8 | 35.5 | 42.2 | NS |
Safety climate |
58.3
|
61.1
|
69.8
|
p < 0.0001
|
Work conditions | 45.6 | 37.9 | 49.5 | NS |
Recognition of stress level | 49.4 | 43.9 | 47.3 | NS |
Total |
56.1
|
53.8
|
60.2
|
p = 0.005
|
Process indicators
Evaluated patients (IPR-AASTRE, %) Total | Evaluated patients (IPR-AASTRE, %) Quarter 1 | Evaluated patients (IPR-AASTRE, %) Quarter 2 | Evaluated patients (IPR-AASTRE, %) Quarter 3 |
p
| |
---|---|---|---|---|---|
Block 1. Mechanical ventilation | |||||
1. Alveolar pressure limit | 124 (26.6) | 71 (26.8) | 20 (45.0) | 33 (15.2) | 0.12 |
2. Mechanical ventilation alarms | 398 (31.2) | 155 (34.2) | 119 (33.6) | 124 (25.0) | 0.001 |
3. Tolerance to spontaneous ventilation | 175 (1.1) | 59 (1.7) | 56 (0.0) | 60 (1.7) | 0.62 |
4. Suitable current volume | 336 (1.5) | 17 (2.6) | 107 (0.9) | 112 (0.9) | 0.47 |
Block 2. Haemodynamics | |||||
5. Monitor alarms | 557 (21.5) | 223 (23.3) | 142 (23.9) | 192 (17.7) | <0.0001 |
6. Water balance and fluid adjustment | 557 (1.1) | 223 (0.5) | 142 (0.7) | 192 (2.8) | 0.36 |
7. Adequate haemodynamic monitoring | 556 (0.4) | 223 (0.0) | 141 (0.7) | 192 (0.5) | 0.49 |
8. Fluid therapy and amines adjustment according to monitoring | 93 (1.1) | 40 (0.0) | 19 (0.0) | 34 (2.9) | 0.41 |
Block 3. Renal function and CRRT | |||||
9. Acute renal failure assessment | 654 (11.8) | 280 (14.6) | 160 (10.6) | 214 (8.9) | 0.03 |
10. CRRT treatment prescription | 27 (3.7) | 13 (0.0) | 6 (0.0) | 8 (12.5) | 0.29 |
11. CRRT monitoring | 28 (0.0) | 14 (0.0) | 6 (0.0) | 8 (0.0) | Not calculable |
Block 4. Sedation/analgesia | |||||
12. Evaluation of sedation level and pain of sedated patient | 199 (11.6) | 86 (15.1) | 61 (9.8) | 52 (7.7) | 0.30 |
13. Pain assessment in non-sedated patient | 396 (8.6) | 137 (13.1) | 110 (5.5) | 149 (6.7) | 0.19 |
14. Oversedation prevention | 132 (9.8) | 65 (10.8) | 42 (2.4) | 25 (20.0) | 0.16 |
Block 5. Treatment (1) | |||||
15. Check drug allergies and intolerances in patient’s medical history | 623 (4.8) | 268 (4.1) | 161 (6.8) | 194 (1.6) | 0.10 |
16. Correct prescription of daily treatment orders | 623 (4.8) | 268 (5.6) | 161 (4.9) | 194 (3.6) | 0.66 |
17. Adequate indication and dosage of the prescribed medication | 622 (3.9) | 268 (4.9) | 160 (3.8) | 194 (2.6) | 0.37 |
18. Prescribed treatment administered correctly. Verbal orders | 623 (1.9) | 268 (3.4) | 161 (0.0) | 194 (1.6) | <0.0001 |
Block 6. Treatment (2) | |||||
19. Prevention of thromboembolic disease | 549 (4.9) | 249 (7.2) | 146 (3.4) | 154 (2.6) | 0.04 |
20. Prophylaxis of gastrointestinal haemorrhage | 587 (0.3) | 266 (0.4) | 159 (0.0) | 162 (0.6) | 0.63 |
21. Control of hyperglycaemia | 588 (1.4) | 264 (1.5) | 160 (1.3) | 164 (1.2) | 0.85 |
22. Assessment of the antibiotic treatment | 436 (2.3) | 195 (3.1) | 119 (0.8) | 122 (2.5) | 0.43 |
23. Appropriate transfusion | 554 (0.2) | 233 (0.0) | 157 (0.6) | 164 (0.0) | 0.49 |
Block 7. Techniques and tests | |||||
24. Checking of X-ray slides | 539 (1.5) | 186 (1.6) | 165 (2.4) | 188 (0.5) | 0.34 |
25. Daily assessment of the need for catheters | 624 (16.8) | 225 (16.0) | 183 (19.7) | 216 (15.3) | 0.46 |
Block 8. Nutrition | |||||
26. Monitoring of enteral nutrition | 487 (24.6) | 241 (27.0) | 117 (27.4) | 129 (17.8) | 0.11 |
27. Daily assessment by parenteral nutrition team | 78 (23.1) | 24 (4.2) | 25 (24.0) | 29 (37.9) | 0.04 |
Block 9. Nursing care | |||||
28. Verification of endotracheal tube cuff pressure | 436 (0.5) | 195 (0.0) | 127 (0.8) | 114 (0.9) | 0.58 |
29. Oral hygiene with chlorhexidine (0.12–0.2%) | 476 (0.4) | 217 ((0.5) | 138 (0.7) | 121 (0.0) | 0.52 |
30. Daily assessment of the risk of developing pressure ulcers | 563 (12.3) | 282 (18.1) | 151 (6.6) | 130 (6.2) | <0.0001 |
31. Daily assessment of the protective measures for the safe handling of the patient | 557 (1.1) | 281 (1.1) | 148 (1.4) | 128 (0.8) | 0.47 |
32. Semi-recumbent position | 433 (21.7) | 196 (20.9) | 123 (24.4) | 114 (20.2) | 0.48 |
Block 10. Structure | |||||
33. Unequivocal patient identification | 594 (12.5) | 243 (14.4) | 190 (12.1) | 161 (9.9) | 0.42 |
34. Patient clinical information properly structured in the medical history | 592 (24.8) | 243 (26.3) | 189 (29.1) | 160 (17.5) | 0.06 |
35. Life-sustaining treatment limit sheet updated | 82 (9.8) | 30 (10.0) | 22 (4.5) | 30 (13.3) | 0.44 |
36. Correct position of bed rails | 584 (0.3) | 240 (0.8) | 185 (0.0) | 159 (0.0) | 0.24 |
37. Information to family members | 592 (0.2) | 242 (0.4) | 189 (0.0) | 161 (0.0) | 0.46 |
Ratio Patients:nurses OR (95% CI) | Ratio Patients: physicians OR (95% CI) | SOFA OR (95% CI) | Patient type OR (95% CI) | Length of stay OR (95% CI) | |
---|---|---|---|---|---|
Mechanical ventilation |
2.6 (1.1–6.7)
| 0.9 (0.7–1.0) |
1.4 (1.1–1.7)
| 1.1 (1.0–1.4) | 0.9 (073–1.0) |
Haemodynamics |
2.9 (1.2–7.4)
| 0.9 (0.6–1.3) | 0.9 (0.7–1.3) | 0.9 (0.8–1.2) | 0.9 (0.8–1.2) |
Renal function/CRRT | 0.3 (0.0–1.4) | 0.9 (0.6–1.4) |
2.0 (1.5–2.5)
| 1.1 (0.9–1.4) | 0.9 (0.8–1.1) |
Sedation and analgesia | 0.9 (0.2–3.5) | 0.9 (0.5–1.3) | 1.2 (0.8–1.7) | 1.0 (0.8–1.3) | 0.9 (0.7–1.1) |
Treatment 1 | 0.5 (0.1–2.7) | 1.4 (0.9–2.0) |
1.4 (1.1–1.8)
| 0.9 (0.8–1.1) |
0.8 (0.6–0.9)
|
Treatment 2 | 1.5 (0.2–11.1) | 1.5 (0.9–2.5) | 1.1 (0.8–1.7) | 0.9 (0.7–1.3) |
0.6 (0.4–0.8)
|
Techniques and tests | 1.3 (0.4–3.6) | 0.6 (0.4–1.9) | 0.9 (0.7–1.2) | 0.9 (0.8–1.2) |
0.7 (0.5–0.9)
|
Nutrition | 0.5 (0.1–2.5) | 1.2 (0.8–1.6) | 0.9 (0.8–1.3) | 1.1 (0.9–1.3) | 0.9 (0.8–1.1) |
Nursing care | 1.2 (0.5–3.2) | 1.1 (0.8–1.4) |
1.4 (1.1–1.7)
| 0.9 (0.8–1.1) | 0.9 (0.8–1.2) |
Structure | 1.0 (0.4–2.5) | 1.0 (0.7–1.2) | 1.2 (1.0–1.5) | 1.1 (0.9–1.3) | 0.9 (0.8–1.1) |
Outcome indicators
Year | Hospital 1 | Hospital 2 | ||||
---|---|---|---|---|---|---|
2012 | 2013 |
p
| 2012 | 2013 |
p
| |
Number of patients | 967 | 1018 | 939 | 927 | ||
APACHE II | 10.4 | 11.2 | 0.39 | 14.9 | 14.4 | 0.72 |
ICU average LOS (days) | 3.3 | 4.0 | 0.09 | 7.7 | 7.9 | 0.07 |
ICU gross mortality (%) | 4.0 | 5.1 | 19.0 | 16.1 | ||
ICU standardized mortality by APACHE 2012 (%) | 4.0 | 4.3 | 0.23 | 19.0 | 16.5 | 0.15 |
VAP rate (No. of VAP episodes/1000 days MV) | 4.2 | 0.9 | 7.9 | 4.0 | ||
IDR VAP2013/2012 (95% confidence interval) | 0.2 (0.05–0.9) | 0.02 | 0.5 (0.3–0.9) | 0.03 | ||
CRB rate (No. of CRB episodes/1000 days of central venous catheter) | 3.9 | 1.5 | 2.8 | 4.8 | ||
CRB IDR2013/2012 (95% confidence interval) | 0.4 (0.1–1.2) | 0.42 | 1.7 (0.7–3.9) | 0.10 |