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

Alireza Jeddian, Karla Hemming, Antje Lindenmeyer, Arash Rashidian, Leila Sayadi , Nazila Jafari, Reza Malekzadeh, Tom Marshall

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    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: 7,802 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.
    Trial registration number IRCT201107187053N1
    Original languageEnglish
    JournalJournal of Critical Care
    Early online date26 Jul 2016
    DOIs
    Publication statusPublished - 1 Dec 2016

    Keywords

    • Critical care outreach
    • stepped wedge randomised controlled trial
    • hospital mortality
    • cardiopulmonary resuscitation
    • length of stay
    • health service evaluation

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