Kim Eagle , MD , and the editors of ACC . org , present relevant articles taken from various journals .
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Kim Eagle , MD , and the editors of ACC . org , present relevant articles taken from various journals .
Use of Care Process Checklists May Not Result in Quality Improvement in ICUs
The use of checklists and other interventions had no significant effect on quality improvement among critically ill patients in intensive care units ( ICUs ), according to a study published in the Journal of the American Medical Association .
The study ’ s researchers , led by Alexandre B . Cavalcanti , MD , PhD , conducted a cluster randomized trial between April and Nov 2014 in 118 ICUs in Brazil . After an assessment of baseline data , 3,327 patients were assigned to the intervention group and 3,434 were assigned to the routine care group .
Intervention care entailed daily rounds modified to include the use of a checklist , discussion of goals of care , and clinician prompting to ensure follow-through with checklist adherence and goals of care for all patients during their ICU stay . The checklist targeted 11 care processes aimed at preventing complications , improving nutrition , reduction in sedation , assessment of readiness for extubation , detection of severe sepsis and acute respiratory distress syndrome , optimization of antibiotics and reduction of tidal volume .
In-hospital deaths , the primary outcome , occurred in 32.9 % of patients in the intervention group and 34.8 % of patients in the routine care group . Secondary exploratory clinical outcomes , including ICU mortality , central line-associated bloodstream infection , ventilator-associated pneumonia , and urinary tract infections were not affected by the intervention measures . “ Low income countries such as Brazil sustain 85 % of the global burden of critical illness ,” the study ’ s authors noted . “ Adherence with guidelines is lower , and severityadjusted outcomes are higher than in high-income countries .”
Because the use of checklists has shown to improve work climate and process adherence in such settings , the authors “ hypothesized that such an approach would improve work climate , care processes , and mortality in Brazilian ICUs .” After analyzing the study ’ s findings , the authors suggest several potential explanations for the lack of quality improvement , including a limited observation period , possible negligible effects of the actual checklist items , and the presence of multiple unadjusted comparisons .
Kim A . Eagle , MD , editor-in-chief of ACC . org , adds that “ the airline industry proved 50 years ago that checklists improved the safety of air travel ; multiple studies have shown that checklists improve outcomes for surgery . ICU care , by virtue of the heterogeneity of the patients , may be a bit different . Checklists work when there is evidence that a particular care strategy is effective and there is practice variation around that care . In this case , the nature of the patients may be such that it is hard to identify strategies that pertain to all of the patients .”
Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network ( BRICNet ). JAMA . 2016 ; 315 ( 14 ): 1480-1490 .
More Healthy Foods May Be Key to Heart Disease Prevention
Eating more healthy foods may be more beneficial than eating fewer unhealthy foods when it comes to secondary preventions of coronary artery disease . These findings , published in the European Heart Journal , add further support for the Mediterranean diet .
The study , which included data from the STABILITY ( Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy ) trial , focused on patients with stable coronary heart disease ( CHD ). Participants were asked to complete a lifestyle questionnaire that included questions on common foods consumed . A Mediterranean diet score was calculated for increasing consumption of whole grains , fruits , vegetables , legumes , fish , alcohol and less meat , while a Western dietary score was created for increasing consumption of refined grains , sweets and desserts , sugared drinks , and deep fried foods . The primary outcome of interest was major adverse cardiac events ( MACE ) defined as cardiovascular death , nonfatal myocardial infarction ( MI ), or nonfatal stroke .
A total of 15,482 patients ( mean age 67 years ) from 39 countries were included in the analysis . Over a median follow-up of 3.7 years , MACE occurred in 1,588 ( 10.1 %) of study participants , including 623 ( 4 %) cardiovascular deaths , 698 ( 4.4 %) nonfatal myocardial infarctions , and 267 ( 1.7 %) non-fatal strokes . Additionally , 1,159 ( 7.3 %) patients died from all causes . There was no association in increase in the Western diet score and MACE , but there was a non-linear association between the Mediterranean diet score and MACE . For Mediterranean diet scores > 12 , a one unit increase in Mediterranean diet score was associated with a lower risk of MACE , and this association remained after stepwise adjustment for covariates . MACE occurred in 7.3 % of the 2,885 subjects with a Mediterranean diet score ≥ 15 , 10.5 % of 4018 subjects with a Mediterranean diet score of 13 – 14 and 10.8 % of 8579 subjects with a Mediterranean diet score ≤ 12 . Event rates for MACE were similar for all quartiles of Western diet scores .
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