Evaluation of a critical care outreach service in a middle-income country: a stepped wedge cluster randomised trial and nested qualitative study

• Published in: Journal of critical care 2016-12, Vol.36, p.212-217
• Main Authors: Jeddian, Alireza, PhD, Hemming, Karla, PhD, Lindenmeyer, Antje, PhD, Rashidian, Arash, PhD, Sayadi, Leila, PhD, Jafari, Nazila, MD, Malekzadeh, Reza, PhD, Marshall, Tom, PhD
• Format: Article
• Language: English
• Subjects: Adult; Attitude of Health Personnel; Cardiopulmonary resuscitation; Cardiopulmonary Resuscitation - statistics & numerical data; Cluster Analysis; CPR; Critical Care; Critical Care Nursing - methods; Critical care outreach; Data collection; Female; Health service evaluation; Hospital Mortality; Hospitalization; Hospitals, University; Humans; Intensive care; Iran; Length of Stay; Logistic Models; Male; Middle Aged; Mortality; Nurses; Odds Ratio; Patients; Patients' Rooms; Qualitative Research; Stepped wedge randomized controlled trial; Surgery; Young Adult
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2016.07.018

Abstract Purpose This trial evaluates implementation of critical care outreach in a middle-income country. Materials and Methods Critical care outreach delivered by a team of intensive care nurses was implemented across general hospital wards in an Iranian university hospital. The order of implementation was randomised with wards stratified by predicted mortality rates. Effectiveness was evaluated using a stepped wedge cluster randomised controlled trial design, comparing outcomes between patients admitted before and after implementation. The primary outcomes were in-hospital mortality and cardiopulmonary resuscitation. A nested qualitative study explored challenges to implementation and contextualised the trial outcomes. Results Between July 2010 and December 2011, 13 wards were sequentially randomised to implement the critical care outreach: 7802 patients were admitted before implementation and 10 880 after implementation. There were 370 deaths (4.74%) among patients admitted before implementation and 384 deaths (3.53%) after implementation. Adjusting for clustering and temporal trends, the odds ratio for mortality was 1.03 (95% CI: 0.68–1.53). Results for other outcomes were broadly similar. Focus groups revealed a lack of endorsement of the intervention by management and ward nurses. Conclusions This pragmatic evaluation of critical care outreach in a middle income country did not show a reduction in mortality or other outcomes.