The Effect of a Quality Improvement Collaborative to Improve Antimicrobial Prophylaxis in Surgical Patients

A Randomized Trial

7 October 2008 | Volume 149 Issue 7 | Pages 472-480

Background: Quality improvement collaboratives are used to improve health care quality, but their efficacy remains controversial.

Objective: To assess the effects of a quality improvement collaborative on preoperative antimicrobial prophylaxis.

Design: Longitudinal cluster randomized trial, with the quality improvement collaborative as the intervention.

Setting: United States.

Participants: 44 acute care hospitals, each of which randomly sampled approximately 100 selected surgical cases (cardiac, hip or knee replacement, and hysterectomy) at both the baseline and remeasurement phases.

Intervention: All hospitals received a comparative feedback report. Hospitals randomly assigned to the intervention group (n = 22) participated in a quality improvement collaborative comprising 2 in-person meetings led by experts, monthly teleconferences, and receipt of supplemental materials over 9 months.

Measurements: Change in the proportion of patients receiving at least 1 antibiotic dose within 60 minutes of surgery (primary outcome) and change in the proportions of patients given any antibiotics, given antibiotics for 24 hours or less, given an appropriate drug, and given a single preoperative dose and receipt of any of the 5 measures (secondary outcome).

Results: The groups did not differ in the change in proportion of patients who received a properly timed antimicrobial prophylaxis dose (–3.8 percentage points [95% CI, –13.9 to 6.2 percentage points]) after adjustment for region, hospital size, and surgery type. Similarly, the groups did not differ in individual measures of antibiotic duration; use of appropriate drug; receipt of a single preoperative dose; or an all-or-none measure combining timing, duration, and selection.

Limitations: Hospitals volunteered for the effort, thereby resulting in selection for participants who were motivated to change. Implementation of the surgical infection prevention measure reporting requirements by the Centers for Medicare & Medicaid Services and The Joint Commission may have motivated improvement in prophylaxis performance.

Conclusion: At a time of heightened national attention toward measures of antimicrobial prophylaxis performance, the trial did not demonstrate a benefit of participation in a quality improvement collaborative over performance feedback for improvement of these measures.

Editors' Notes Context Quality improvement collaboratives are widely used to promote safety and quality initiatives. Contribution This cluster randomized trial demonstrated that a quality improvement collaborative provided no added benefit over feedback alone for improving the quality of preoperative antimicrobial prophylaxis. Caution Hospitals volunteered and may have already been motivated to improve their practices. Mandatory reporting requirements may also have motivated improvements independent of the study interventions. Implication Quality improvement collaboratives are not necessarily effective ways to promote quality improvement. —The Editors

 

Author and Article Information

From Wake Forest University School of Medicine and J. Paul Sticht Center on Aging, Winston-Salem, North Carolina; The Joint Commission, Oakbrook Terrace, Illinois; University of Tennessee, Memphis, Tennessee; LDS Hospital, Salt Lake City, Utah; McGuire Veterans Affairs Medical Center and Medical College of Virginia, Richmond, Virginia; Centers for Disease Control and Prevention, Atlanta, Georgia; and Methodist Health Systems, Memphis, Tennessee.

Acknowledgment: The authors thank the study participants for their hard work and dedication to accurate data collection and Cheryl Richards, BS, RHIA; James Steinberg, MD; Mark Beezhold; Nancy Spector, RN, MSC; Richard Koss, MA; and Jerod M. Loeb, PhD.

Grant Support: By grant R01 HS11331-01A1 from the Agency for Healthcare Research and Quality and initial support from the Centers for Disease Control and Prevention.

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Braun (bbraun{at}jointcommission.org). Data set: Available contigent on purpose through written agreement by contacting Dr. Kritchevsky (skritche{at}wfubmc.edu).

Requests for Single Reprints: Barbara I. Braun, PhD, Division of Quality Measurement and Research, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181; e-mail, bbraun{at}jointcommission.org.

Current Author Addresses: Dr. Kritchevsky and Mr. Davis: Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157.

Dr. Braun, Ms. Bozikis, and Ms. Kusek: Division of Quality Measurement and Research, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181.

Dr. Bush: Department of Preventive Medicine, University of Tennessee, 66 North Pauline, Suite 633, Memphis, TN 38105.

Dr. Burke: Division of Infectious Diseases, LDS Hospital, 8th Avenue and C Street, Salt Lake City, UT 84143.

Dr. Wong: McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249.

Dr. Jernigan: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop E-68, Atlanta, GA 30333.

Dr. Simmons: Quality Management, Methodist Health System, 1211 Union, Suite 811, Memphis, TN 38104.

Author Contributions: Conception and design: S.B. Kritchevsky, B.I. Braun, E.S. Wong, B. Simmons.

Analysis and interpretation of the data: S.B. Kritchevsky, B.I. Braun, A.J. Bush, E.S. Wong, C.C. Davis, B. Simmons.

Drafting of the article: S.B. Kritchevsky, B.I. Braun, M.R. Bozikis, E.S. Wong, J. Jernigan, C.C. Davis, B. Simmons.

Critical revision of the article for important intellectual content: S.B. Kritchevsky, J.P. Burke, E.S. Wong, J. Jernigan, B. Simmons.

Final approval of the article: S.B. Kritchevsky, J.P. Burke, E.S. Wong, J. Jernigan, C.C. Davis, B. Simmons.

Provision of study materials or patients: S.B. Kritchevsky, L. Kusek, B. Simmons.

Statistical expertise: S.B. Kritchevsky, C.C. Davis, A.J. Bush.

Obtaining of funding: S.B. Kritchevsky, B. Simmons.

Administrative, technical, or logistic support: B.I. Braun, L. Kusek, J. Jernigan.

Collection and assembly of data: B.I. Braun, L. Kusek.

ClinicalTrials.gov registration number: NCT00114036.

^* For members of the TRAPE Study Group, see the Appendix.

Read all Rapid Responses

Do Quality Improvement Collaboratives Improve Antimicrobial Prophylaxis in Surgical Patients?

Stephen K. Liu, et al.

Annals Online, 24 Oct 2008 [Full text]

suggestions to the authors

Daisson José Trevisol, et al.

Annals Online, 24 Nov 2008 [Full text]

Response to Dr. Liu and colleagues

Stephen B Kritchevsky, et al.

Annals Online, 3 Dec 2008 [Full text]