Redouane Bouali

Implementation of Clinical Practice Guidelines for Ventilator-associated Pneumonia: A Multicenter Prospective Study*

Objective:Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. Design:Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. Setting:Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. Patients:At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). Intervention:Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. Measurements and Main Results:The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). Conclusions:A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

Comprehensive assessment of critical care needs in a community hospital

Objective:To design and implement a needs assessment process that identifies gaps in caring for critically ill patients in a community hospital. Design, Setting, Subjects:This mixed-method study was conducted between June 2011 and February 2012. A conceptual framework, centered on the critically ill patient, guided the design and selection of the data collection instruments. Different perspectives sampled included regional leaders, healthcare professionals at the community hospital and its referral hospital, as well as family members of patients who had received care at the community ICU. Data sources included interviews (n = 22), walk-throughs (n = 5), focus groups (n = 31), database searches, context questionnaires (n = 8), family surveys (n = 16), and simulations (n = 13). Interventions:None. Measurements and Main Results:Nine needs were identified. At the community hospital, needs identified included lack of access to human resources, gaps in expertise, poor patient flow and ICU bed use, communication, lack of educational opportunities, and gaps in end-of-life care and interprofessional teamwork. Needs were also identified in the interhospital interaction between the community and referral hospitals, which included an inadequate hospital network and gaps in transfer and repatriation of patients. The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. Proposed solutions by the participants are presented including both organizational and educational/clinical solutions. Conclusions:This study captured needs in a complex, interprofessional, interhospital context, which can be targeted with tailored interventions to improve patient outcomes in a community hospital. Furthermore, this study provides a preliminary framework and rigorous methodology to performing a needs assessment in this setting.

15th Annual Congress of the European Society of Intensive Care Medicine, 29 September–2 October 2002, Barcelona, Spain: Clinical research to improve outcome

The 15th Annual European Society of Intensive Care Medicine Meeting opened in Barcelona, Spain on September 30, 2002. This report focuses on some highlights of this congress. Preliminary data from the Sepsis Occurrence in the Acutely ill Patient (SOAP) study are presented, as are findings from the Assessment of Low Tidal Volume and Elevated End-Expiratory Volume to Obviate Lung Injury (ALVEOLI) study, which compared higher positive end-expiratory pressure (PEEP)/lower fractional inspired oxygen (FiO2) with lower PEEP/higher FiO2 strategies. We also present a study that compared continuous with intermittent renal replacement therapies. Finally, the seven posters that received an award are summarized.

Multidisciplinary educational needs assessment of critical care in community hospitals

Performing a needs assessment is essential to ensure that educational interventions and materials created will address areas of deficit in the learners knowledge/skills. The goal of this Ministry-funded project was to determine the educational needs of healthcare professionals from community hospitals in the context of Ontarios Critical Care Strategy (CCS). The study hypothesis was that a novel model, applying sound principles of education research, must be created to concomitantly assess the needs of multiple disciplines.