Knowledge translation in critical care: Factors associated with prescription of commonly recommended best practices for critically ill patients*

Objective:To describe prescription rates of commonly recommended best practices (clinical interventions with a strong base of evidence supporting their implementation) for critically ill patients and determine factors associated with increased rates of prescription. Design:A retrospective observational study. Setting:A university-affiliated medical-surgical-trauma intensive care unit over a 1-yr period. Patients:One hundred randomly selected critically ill patients. Interventions:None. Measurements and Main Results:Among the best practices studied, there was great variability in the proportion of patients eligible (median 36.5%, range 10% to 100%) and the proportion without contraindication (32.5%, range 10% to 86%) for each practice. The median rate of prescription of best practices for eligible patients was 56.5%, with a range from 8% to 95%. There was greater prescription of best practices when standard admission orders included an option to prescribe them (p = .048). Among those practices with standard admission orders, there was greatest prescription for practices additionally having a specialty consultation service (p = .004). There was an inverse association between severity of illness and prescription of best practices (p = .001): Sicker patients were less likely to be prescribed best practices. Conclusions:There may be substantial variability in the acceptance and prescription of commonly recommended best practices for critically ill patients. Standard order sets and focused specialty consultation may improve knowledge translation and prescription of best practice.

[1]  A. Wallace,et al.  Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. , 1996, The New England journal of medicine.

[2]  S. Green.  How Many Subjects Does It Take To Do A Regression Analysis. , 1991, Multivariate behavioral research.

[3]  T. Girard,et al.  Ultrasound guidance during central venous catheterization: a survey of use by house staff physicians. , 2005, Journal of critical care.

[4]  Daniel Talmor,et al.  Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol* , 2006, Critical care medicine.

[5]  K. McDonald,et al.  Making health care safer: a critical analysis of patient safety practices. , 2001, Evidence report/technology assessment.

[6]  T. Stewart.  Controversies around lung protective mechanical ventilation. , 2002, American journal of respiratory and critical care medicine.

[7]  F. Rogers,et al.  Prevention of stress ulceration: Current trends in critical care , 2004, Critical care medicine.

[8]  Mark Mikkelsen,et al.  Underuse of lung protective ventilation: Analysis of potential factors to explain physician behavior* , 2006, Critical care medicine.

[9]  C. Colwell,et al.  Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. , 2004, Chest.

[10]  A. Day,et al.  Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: Results of a prospective observational study* , 2004, Critical care medicine.

[11]  Peter J Pronovost,et al.  Improving care for the ventilated patient. , 2004, Joint Commission journal on quality and safety.

[12]  Peter J Pronovost,et al.  Eliminating catheter-related bloodstream infections in the intensive care unit* , 2004, Critical care medicine.

[13]  G. Guyatt,et al.  Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force. , 2006, Chest.

[14]  Miquel Ferrer,et al.  Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial , 1999, The Lancet.

[15]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[16]  M Schetz,et al.  Intensive insulin therapy in critically ill patients. , 2001, The New England journal of medicine.

[17]  G. Rubenfeld,et al.  Barriers to providing lung-protective ventilation to patients with acute lung injury , 2004, Critical care medicine.

[18]  Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock , 2003, Current infectious disease reports.

[19]  William C. Cockerham.  Physicians , 2001, BMJ : British Medical Journal.

[20]  D. Hinshaw,et al.  The safety checklist program: creating a culture of safety in intensive care units. , 2002, The Joint Commission journal on quality improvement.

[21]  Jeremy M. Grimshaw,et al.  Changing Provider Behavior: An Overview of Systematic Reviews of Interventions , 2001, Medical care.

[22]  B. Bistrian,et al.  Intensive insulin therapy in critically ill patients. , 2002, The New England journal of medicine.

[23]  M. Levy,et al.  A descriptive evaluation of transfusion practices in patients receiving mechanical ventilation. , 2005, Chest.

[24]  J. Botha,et al.  The state of sedation in the nation: results of an Australian survey. , 2005, Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine.

[25]  J. Mattana,et al.  Lack of physician concordance with guidelines on the perioperative use of beta-blockers. , 2004, Archives of internal medicine.

[26]  V. Montori,et al.  Improving patients' safety locally: changing clinician behaviour , 2004, The Lancet.

[27]  K. Inman,et al.  Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. , 1993, JAMA.

[28]  D. Cook,et al.  Prevention of venous thromboembolism in critically ill medical patients: a Franco-Canadian cross-sectional study. , 2003, Journal of critical care.

[29]  Checkoffs play key role in SICU improvement. , 2003, Hospital case management : the monthly update on hospital-based care planning and critical paths.

[30]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[31]  J Ean,et al.  Efficacy and safety of recombinant human activated protein C for severe sepsis. , 2001, The New England journal of medicine.

[32]  D. Fry,et al.  Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. , 2005, Archives of surgery.

[33]  Brian S. Mittman,et al.  Changing Provider Behavior , 1992 .

[34]  S. Kleinman,et al.  A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care , 1999 .

[35]  E. Draper,et al.  APACHE II: A severity of disease classification system , 1985, Critical care medicine.

[36]  J. Kress,et al.  Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. , 2000, The New England journal of medicine.

[37]  G. Pagliarello,et al.  Prophylactic beta-blockade to prevent myocardial infarction perioperatively in high-risk patients who undergo general surgical procedures. , 2003, Canadian journal of surgery. Journal canadien de chirurgie.

[38]  G. Guyatt,et al.  Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. , 1996, JAMA.

[39]  G. Van den Berghe,et al.  Intensive insulin therapy in the medical ICU. , 2006, The New England journal of medicine.

[40]  STRESS ULCER PROPHYLAXIS IN CRITICALLY ILL PATIENTS , 1989, The Lancet.

[41]  D. Cook,et al.  Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. , 1999, Critical care medicine.

[42]  M. Cabana,et al.  Why don't physicians follow clinical practice guidelines? A framework for improvement. , 1999, JAMA.

[43]  F. Cerra,et al.  Applied nutrition in ICU patients. A consensus statement of the American College of Chest Physicians. , 1997, Chest.

[44]  D. Cook,et al.  Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units. , 2002, Journal of critical care.

[45]  T. Evans,et al.  Glucose control and mortality in critically ill patients. , 2004, JAMA.

[46]  W. Hendee.  To Err is Human: Building a Safer Health System , 2001 .

[47]  A. Shillington,et al.  Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs. , 2005, Journal of vascular surgery.