38: CERTAIN: AN INTERNATIONAL QUALITY IMPROVEMENT STUDY IN THE INTENSIVE CARE UNIT

Abstract

Learning Objectives: To facilitate timely and accurate bestpractice delivery in critically ill patients in ICUs with variable resources, an international collaborative developed CERTAIN (Checklist for early recognition and treatment of acute illness and injury), a remote simulation training and web-based decision support tool for structured ICU admission and rounding. Method(s): This was a pragmatic multifaceted before-after study in 36 ICUs in 10 low-and middle-income countries and 5 highincome countries. Data were collected in a 3-month period before and a 6-month period after a structured implementation of CERTAIN. The primary outcome was the delivery of 10 basic care practices; secondary outcomes included selected ICU quality of care indicators. Result(s): We collected data from 1,532 and 2,906 patients before and after implementation. After adjusting for center characteristics and ICU days observed, implementation of CERTAIN was associated with fewer omissions in basic care practices: deep vein thrombosis prophylaxis (Relative Risk: 0.70 [95%CI 0.64-0.76]), peptic ulcer prophylaxis (0.44 [0.37-0.53]), daily oral care (0.77 [0.64-0.93]), assessment of need for antimicrobials (0.72 [0.68- 0.77]) and sedation (0.67 [0.62-0.73]), and family conferences (0.88 [0.82-0.93]), but not for head of bed elevation (0.91 [0.75- 1.13]). There was higher adherence to daily assessment of removal of central lines (1.23 [1.16-1.31]) and urinary catheters (1.39 [1.31-1.47]), and spontaneous breathing trial (1.31 [1.22-1.40]). Infections of central lines (0.52 [0.36-0.75]) and urinary catheters (0.69 [0.53-0.90]) were reduced, but risk of ventilator-associated pneumonia (1.24 [1.11-1.39]) increased. The probability of plasma transfusion was lower (0.79 [0.67-0.85]). Conclusion(s): In an international sample of ICUs, a structured quality improvement intervention consisting of remote simulation training and a web-based decision support tool was associated with improved adoption of basic care practices and improvement in selected ICU quality of care indicators.