Measurable Outcomes of Quality Improvement in the Trauma Intensive Care Unit: The Impact of a Daily Quality Rounding Checklist

Abstract

OBJECTIVE: The use of "care bundles" in the prevention of ventilator-associated pneumonia (VAP) and other intensive care unit (ICU) complications have been increasingly used in critical care practice. However, the effective implementation of these strategies represents a challenge in a busy Level I trauma ICU. We devised a daily "Quality Rounds Checklist" (QRC) tool for use in the ICU to increase compliance with these prophylactic measures and identify areas for improvement in quality of care. METHODS: A prospective before-after design was used to examine the effectiveness of the QRC tool in promoting compliance with 16 prophylactic measures for VAP, deep venous thrombosis or pulmonary embolism, central line infection and other ICU complications. Compliance was assessed for 1 month before institution of the QRC. On daily analysis, the QRC was then applied by the ICU fellow to assess compliance. Any deficiencies were actively corrected in real time. Compliance was assessed by a multidisciplinary team for the next 3 months and compared with the pre-QRC compliance rates. RESULTS: Implementation of the QRC tool facilitated improvement of all measures not already at >95% compliance. Compliance with VAP prevention measures of head of bed elevation >30 degrees (35.2% vs. 84.5%), sedation holiday (78.0% vs. 86.0%), and prophylaxis for both peptic ulcer disease (76.2% vs. 92.3%) and deep venous thrombosis (91.4% vs. 92.8%) were all increased. A decrease in central line duration >72 hours (62.4% vs. 52.8%) and ventilator duration >72 hours (74.0% vs. 61.7%) was also noted. Additionally, a decrease in mean monthly rates per 1,000 device days of VAP (16.3 vs. 8.9), central line infection (11.3 vs. 5.8) and self-extubation (7.8 vs. 2.2) was demonstrated. CONCLUSION: Introducing a daily QRC tool facilitated improved compliance rates for 16 clinically significant prophylactic measures in a busy Level I trauma ICU. The daily use of this tool, requiring just a few minutes per patient to complete, results in a sustainable improvement in patient outcomes.