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American Journal of Critical Care. 2006;15: 549-555
Copyright © 2006 by the American Association of Critical-Care Nurses.
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Journal Club Feature

Using Evidence and Process Improvement Strategies to Enhance Healthcare Outcomes for the Critically Ill: A Pilot Project

By Carol W. Hatler, RN, PhD, Deanna Mast, RN, MSHA, Jeannie Corderella, RN, BS, MHA, Gina Mitchell, RN, Kathleen Howard, RN, CIC, Jackie Aragon, RN, BSN, CPHQ and Deborah Bedker, RN, BSN, CPHQ. From the Departments of Nursing and Infection Control, St. Joseph’s Hospital and Medical Center, Phoenix, Ariz.

Corresponding author: Carol Hatler, RN, PhD, Director, Nursing Research, St. Joseph’s Hospital and Medical Center, 350 W Thomas, Phoenix, AZ 85013 (e-mail: carol.hatler{at}chw.edu).


   Abstract
Top
 Abstract
Background
 Methods
 Results
 Discussion
 References
 
• Background Although the value of evidence-based practice may seem obvious, the process needed to produce more effective delivery of evidence-based healthcare is not obvious. Furthermore, the continuing escalation of healthcare costs fuels the desire of providers and consumers to undertake only those treatments that have benefit. One way to effect necessary changes in healthcare organizations is through focused, interdisciplinary, collaborative projects related to evidence-based practice.

• Objectives To reduce rates of ventilator-associated pneumonia and catheter-related bloodstream infection in patients in the medical intensive care unit of a large, urban tertiary referral hospital in the Southwest.

• Methods The theory of planned behavior served as the basis for providing staff members with research-based, easily controllable strategies that "fit" with the usual methods of care delivery. Implementation of the strategies and data collection were accomplished through routine rounds on patients and regular reporting of objective information.

• Results During a 15-month period, use of the selected strategies resulted in a 54% reduction in ventilator-associated pneumonia, a 78% reduction in catheter-related bloodstream infections, and a 18% reduction in mean length of stay in the unit. Use of a multidisciplinary, environmentally tailored approach to concerns about patients’ care resulted in estimated cost savings of $1.0 million to $2.3 million.

• Conclusions Early, consistent communication about the project’s rationale, expected behavior, and outcomes enhanced the manageability and effectiveness of this change in an adult intensive care unit.

The continuing escalation of healthcare costs, which now account for more than 15% of the US national budget,1 fuels the desire of providers and consumers to undertake only those treatments that produce beneficial results. Berwick2 suggested that unless healthcare providers can deliver on implicit or explicit promises, consumers are likely to distrust providers and organizations. Consumer trust can be fostered by basing interventions on credible evidence; such interventions are more likely to produce consistent and effective results. In this article, we describe an evidence-based practice that was implemented in the medical intensive care unit (MICU) at St. Joseph’s Hospital and Medical Center, a tertiary referral hospital located in Phoenix, Ariz.

ICUs are important areas for implementing evidence-based practices. In the United States, intensive care accounts for 30% of hospital expenses, with an annual cost of $180 billion.3 In the project described here, we focused on practices related to ventilator support because (1) those processes and outcomes could be most readily achieved at our facility and (2) they were issues most likely to receive support in the hospital environment. Because most (76%) of the patients in the MICU needed ventilator support and many had central catheters, we thought that activities aimed at reducing the frequency of ventilator-associated pneumonia (VAP) and catheter-related bloodstream infections (CR-BSIs) could have significant impact.

A number of investigations have underscored the importance of VAPs and CR-BSIs. For example, Rello et al4 examined a large inpatient database from nongovernmental US hospitals and determined that VAPs developed in 9.3% of patients. Among patients in whom VAP developed, the ICU length of stay increased by about 6 days and 30.5% of patients died. Regarding CR-BSI, Hoyert et al5 identified sepsis as the second leading cause of death for patients in noncardiac ICUs, because 20% to 50% of ICU patients in whom sepsis develops do not recover.

For this project, we expected that improvement in rates of VAP and CR-BSI could influence the mean length of stay in the medical ICU and the overall cost of care. Our goal was a 50% reduction in the number of cases of VAP and CR-BSI within 1 year. Several strategies were identified to address VAP; Table 1Go summarizes the activities implemented. The first letters of the interventions created the mnemonic HOTSPUD, which became the term people used to refer to the project. In addition, increased emphasis was placed on routine procedures for infection control such as hand hygiene and maintenance of central venous catheters.


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  		Table 1 Explanation of mnemonic HOTSPUD used to remember activities to implement (ventilator bundle) in the medical intensive care unit to reduce frequency of ventilator-associated pneumonia and catheter-related bloodstream infections

 
Activity changes to address the project goals were based on current, validated evidence and incorporated several relevant modifications to "usual care." Strategies to address VAP were drawn from a study by Zack et al,6 who reported a reduction in VAP of 57.6% during a 12-month period. In a later study, Dodek et al7 determined that similar strategies, including implementing position changes (oral rather than nasal intubation, elevation of the head of the bed) and pharmacological interventions, improved VAP rates.

Strategies to improve outcomes for patients needing central intravenous catheters were reported by Warren et al.8 Using an educational strategy for healthcare providers, these investigators determined that rates of CR-BSI were decreased by 41.5% in a 2-year period, with estimated cost savings of $103 600 to $1 573 000.


   Background
Top
 Abstract
 Background
Methods
 Results
 Discussion
 References
 
Although the value of evidence-based practice may seem obvious, the process needed to produce effective delivery of healthcare is not obvious. Barriers to evidence-based practice are related to the availability and type of evidence, organizational support for evidence-based practice, and characteristics of practitioners such as lack of time and lack of skill needed to apply findings to practice.9 Mackay10 describes a "double-edged sword": organizations recognize the imperative to identify and use effective practices but have little money to support learning, implementation, and evaluation of practice. Berwick11 illustrates this paradox in writing that "health care has developed a very long leg in measurement and a short leg in managing change, and, therefore, it is walking in circles."

To implement the evidence-based strategies for this project effectively, we selected a change theory to guide project implementation, because use of a theory would more closely link processes with outcomes. The theoretical basis for this project was the cognitive theory of planned behavior, originally described by Azjen.12 The theory of planned behavior suggests that individual behavior is influenced by beliefs about the value of the particular (new) behavior, the social norms established within the peer group, and perceived control of and ability to perform the specific behavior. The theory of planned behavior was considered applicable to this project, because changes in attitudes and behaviors were necessary for project implementation.

The theory of planned behavior has been used in a variety of investigations of change in individuals’ behavior. For example, O’Boyle et al13 used the theory of planned behavior to examine healthcare workers’ adherence to hand hygiene recommendations in 4 hospitals in the Midwest. Using self-reported and observed behavior, the investigators determined that an individual’s intention was predictive of self-reported hand hygiene behavior, but the intensity of activity in the unit was most predictive of observed behavior related to hand hygiene. The investigators suggested that concepts associated with the theory of planned behavior, such as intention and perceived control, can be operationalized only when sufficient resources are available to support the desired "new" behavior.

We used the theory of planned behavior to guide the introduction and monitoring phases of our project. After review and approval of the project by the appropriate institutional review board, nurse leaders, the infection control practitioner, and the physician champion provided the staff education sessions that initiated the project.


In terms of evidence-based practice, "health care has developed a very long leg in measurement and a short leg in managing change, and, therefore, it is walking in circles."11

 


   Methods
Top
 Abstract
 Background
 Methods
Results
 Discussion
 References
 
Setting and Sample
Project activities were implemented in the MICU at St. Joseph’s Hospital and Medical Center. The unit consists of 8 beds, staffed by 19 registered nurses, 3 unit secretaries, and 2 nonlicensed assistive personnel. All registered nurses are certified to perform continuous renal replacement therapy, and the nurses who work in the MICU are considered the facility’s experts in continuous renal replacement therapy. The nursing staff for the MICU provides care for the patients in this unit exclusively; a few staff members in the MICU and the other 4 adult ICU areas of the hospital work as needed in any of the units. Selection of the MICU as the trial unit was based on its relatively small size and the willingness of staff members to participate.

Patients in the MICU have a variety of conditions and diagnoses, including acute respiratory failure, diabetic ketoacidosis, intracerebral hemorrhage/infarction, congestive heart failure, acute myocardial infarction, gastrointestinal hemorrhage, malignant neoplasm of the brain or spinal cord, and septicemia. The mean age for patients admitted to the MICU in 2005 was 55 years; 52% of the patients were male.

Intervention
A prominent feature of the planned intervention was the creation of a facility-specific path to achieve outcomes. This context-relevant method of delivering evidence-based interventions enhanced the success of the project and was more readily accepted by health-care providers than an exact replication of strategies from another source. At the study facility, project planners included senior leaders, a clinical process leader, a physician, nurses, the infection control practitioner, and representatives from respiratory therapy and pharmacy. This group of leaders met regularly to monitor progress and to make needed changes during implementation.

The first approach to nursing staff members involved a clear and detailed explanation of new expectations that included the rationale for the change. To maintain consistency with the theory of planned behavior, the staff members received a 1-page document detailing new strategies to address prevention of VAP and CR-BSI, thus increasing their abilities to control and perform the desired behaviors. A chart of expected activities was posted in each patient’s room (Table 1Go outlines project elements).

Daily rounds, led by the unit’s nursing supervisor, helped establish adherence to the targeted procedures as "normal" behavior for staff members. The daily rounds followed a specific format (Table 2Go) and involved a discussion with each staff nurse about his or her patients’ goals for that day, the resources needed to achieve the goals (including physician orders required), and identification of any barriers to use of the "bundled" activities (Table 1Go). Daily goals were posted on white boards in patients’ rooms, facilitating communication about the goals and serving as a visible reminder for those participating in care.


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  		Table 2 Form for daily rounds

 
The nursing supervisor facilitated the daily rounds, which she conducted at a specific time and for which specific information was required. A daily guide for rounds was developed, and staff nurses quickly became familiar with the new routine. Reinforcements in the form of individual thank-you notes and movie tickets helped draw attention to nurses who were early adopters of the changes. Recognition activities established the "new" behavior as the social norm for staff members.


Rapid cycle testing of short trials of patient care activities provides measured outcomes in 2 to 4 weeks and quickly identifies processes that are not working.

 

Infection control professionals provided regular feedback about the rate of adoption of each of the identified strategies and the current rates for VAP and CR-BSI. This regular feedback served to pinpoint areas for improvement as well as successful transitions. The monthly results also designated in which direction efforts should be focused in the coming month.

Communication strategies used to highlight the progress and outcomes of this pilot effort included service-specific newsletters, reports from meetings of the nursing and medical practice councils and the quality management staff, and posting of weekly results on staff bulletin boards. In addition, when significant change was accomplished, staff members, managers, and administrators celebrated with prizes (Mr. Potato-Head was a favorite icon, illustrating the HOTSPUD theme) and catered meals. The number and variety of communication strategies heightened awareness, established expectations, created urgency, and rewarded changes in behavior.

A rapid-cycle approach was used to increase the flexibility of implementing the change. Rapid-cycle testing involves an epidemiological approach (in contrast to an experimental approach) in which staff members use small-scale, short trials of activities related to patients’ care and outcomes are identified by thoughtful and experienced clinicians. In a rapid-cycle test, the new activity is stressed and outcomes are measured for 2 to 4 weeks; successful strategies are kept and unsuccessful activities are abandoned. In real-world circumstances, the usefulness of such short-cycle trials is superior to that of experimental studies because of the many uncontrollable factors in the clinical setting.14

Data Collection
Baseline data including number of patient days, number of ventilator days, number of central catheter days, and total number of cases of CR-BSI and VAP were collected in December 2003.

Routine infection control surveillance was used to collect project data. Criteria for VAP were drawn from the Centers for Disease Control and Prevention15 and were applied to patients with onset of signs and symptoms within 48 hours of intubation. Criteria for CR-BSI were based on work by Garner et al.16 VAP rate was calculated as the number of cases of VAP divided by the number of ventilator days per 1000 ventilator days. The CR-BSI rate involved the number of CR-BSIs divided by the number of central catheter days per 1000 catheter days.


   Results
Top
 Abstract
 Background
 Methods
 Results
Discussion
 References
 
To monitor adoption of the practices, compliance rates for each part of the ventilator bundle were examined and reported monthly. Adherence to all parts of the ventilator bundle started at 73%, but the current adherence rate is 98.6%. Adherence to prophylaxis for deep vein thrombosis seemed to be the intervention with the greatest variability in implementation.

The initial VAP rate for MICU patients was 11.4/1000 ventilator days, but the rate was reduced to 5.3 within 12 months (54% reduction). The VAP rate reduction resulted in 22.5 fewer occurrences during a 1-year period. Reports of costs associated with a single case of VAP range from $11 89717 to a low estimate of $4342.18 When these estimates were used, project cost savings were between $97 695 and $267 683 annually for the improvements in ventilator management.


Using "bundled" interventions, rates of ventilator-associated pneumonia were reduced by 54% and rates of catheter-related bloodstream infections were reduced by 78%.

 

The initial rate of CR-BSIs was 12.8, but the rate within 12 months was 2.88 (78% reduction). Reported costs of sepsis developing range from $370019 to $22 000.20 When the reduced number of sepsis occurrences (total 59.5) resulting from the project’s activities was calculated, the savings associated with improvements in CR-BSIs ranged from $220150 to $1309000 annually.

Mean length of stay in the MICU was reduced to 3.59 days, compared with the initial mean stay of 4.40 days (18% reduction). Noseworthy et al21 suggested that mean costs of ICU care are $1500 per day. When that amount was used to calculate cost savings, the project resulted in savings of $726 570 in a year’s time. The implementation of this multidisciplinary, environmentally tailored approach to concerns about patients’ care resulted in estimated cost savings of $1 044 415 to $2 303 253 in 12 months.


Structures like a regular time for daily rounds, forms for daily rounds, and posting of expected activities enhanced success.

 


   Discussion
Top
 Abstract
 Background
 Methods
 Results
 Discussion
References
 
The results of this project hinged on communication, structure, and flexibility of methods. Early communication with staff members outlining the rationale of the project was delivered by trusted leaders who clearly defined the expectations. Because the MICU staff nurses had a bias for action and a tolerance for ambiguity, giving them an explanation for change several weeks before the implementation date allowed them to ask questions and resolve concerns and to prepare for action. Structures such as a regular time for daily rounds, forms for daily rounds, and posting of expected activities in patients’ rooms increased the manageability of the change behaviors. In addition, rapid-cycle testing helped identify which methods were and were not working, so that needed changes could be made quickly and easily. Staff members were told early in the project that the methods used initially might not work but were assured that processes would be tried until the processes did work. By maintaining flexibility of methods, project leaders were able to shape the strategies to match the unit’s culture.

The cost savings and improvement in quality of patients’ care achieved in this project resulted in implementation of the bundled activities in the facility’s other 4 adult ICUs. In addition, bundled activities to improve glucose control and patients’ safety were introduced into the MICU. Because the HOTSPUD effort proved efficient and effective, staff members have been active and eager participants in developing and implementing the new techniques and in maintaining the successful behaviors. Use of evidence-based activities has produced cost savings that allow the organization to continue enhancing staff recruitment and retention programs.

For others considering strategies similar to the ones described in this article, several issues must be considered. Starting with a small group of patients and staff members can decrease the time and effort needed to try new strategies. A small group of staff members can be immersed in new activities and can refine implementation strategies fairly readily, thus producing a "tested" path to success when a larger group of staff is engaged. In addition, clearly identifying measurable and attainable goals can facilitate changes in behavior. Being able to point out distinctive behavior changes or empirical results can decrease the resistance to change often experienced with organizational change projects. Creating a multidisciplinary team to plan, implement, and evaluate the project allows a more comprehensive approach.22 Also, a multidisciplinary group can provide needed support for project leaders. Finally, the ability to be consistent about expectations and methods is essential to a project’s success. Having the same trusted leaders focus on consistent concerns in a dependable way underscores the importance of the changes in behavior and produces desired results.


   ACKNOWLEDGMENT
 
We thank Dr Philip Fracica for his participation as the physician leader of the efforts reported in this article and for his review of the article’s content. Dr Fracica’s leadership among his physician colleagues and his cooperative efforts have been valuable components of this project.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


   REFERENCES
Top
 Abstract
 Background
 Methods
 Results
 Discussion
 References
 

  1. Smith C, Cowan C, Sensenig A, Catlin A, and the Health Care Accounts Team. Health spending growth slows in 2003. Health Affairs. 2005;24:185–194.[Abstract/Free Full Text]
  2. Berwick DM. Improvement, trust, and the healthcare workforce. Qual Saf Health Care. 2003;12(suppl 1):i2–i6.[Abstract/Free Full Text]
  3. Halpern NA, Bettes L, Greenstein R. Federal and nationwide intensive care units and healthcare costs: 1986–1992. Crit Care Med. 2000;22:2001–2007.
  4. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122:2115–2121.[Abstract/Free Full Text]
  5. Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. Deaths: final data for 1999. Natl Vital Stat Rep. September 21, 2001;49:1–113.[Medline]
  6. Zack J, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30:2407–2412.[Medline]
  7. Dodek P, Kenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141:305–313.[Abstract/Free Full Text]
  8. Warren DK, Zack JE, Mayfield JL, et al. The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest. 2004;126:1612–1618.[Abstract/Free Full Text]
  9. McCaughan D, Thompson C, Cullum N, Sheldon TA, Thompson DR. Acute care nurses’ perceptions of barriers to using research information in clinical decision-making. J Adv Nurs. 2002;39:46–60.[Medline]
  10. Mackay MH. Research utilization and the CNS: confronting the issues. Clin Nurs Spec. 1998;12:232–237.
  11. Berwick D. Crossing the boundary: changing mental models in the service of improvement. Int J Qual Health Care. 1998;10:435–441.[Abstract/Free Full Text]
  12. Azjen I. From intentions to actions: a theory of planned behavior. In: Kuhl J, Beckmann J, eds. Action Control: From Cognition to Behavior. New York, NY: Springer; 1985:11–39. Springer Series in Social Psychology.
  13. O’Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001;29:352–360.[Medline]
  14. Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med. 1998;128:651–656.[Abstract/Free Full Text]
  15. Centers for Disease Control and Prevention. Criteria for determining nosocomial pneumonia: documents—final. 2005. Available at: http://www.cdc.gov/ncidod/hip/NNIS/members/pneumonia/pneumonia_final.htm. Accessed August 15, 2006.
  16. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions of nosocomial infections. In: Olmsted RN, ed. APIC Infection Control and Applied Epidemiology: Principles and Practice. St Louis, Mo: Mosby-Year Book; 1996:A1–A20.
  17. Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med. 2003;31:1312–1317.[Medline]
  18. Dimick JB, Pelz RK, Consumji R, et al. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg. 2001;136:229–234.[Abstract/Free Full Text]
  19. Simmons-Trau D, Cenek P, Counterman J, Hockenbury D, Litwiller L. Reducing VAP with 6 Sigma. Nurs Manage. 2004;35:41–45.[Medline]
  20. Patel GP, Gurka DP, Balk RA. New treatment strategies for severe sepsis and septic shock. Curr Opin Crit Care. 2003;9:390–396.[Medline]
  21. Noseworthy TW, Konopad E, Shustack A, Johnston R, Grace M. Cost accounting of adult intensive care: methods and human and capital inputs. Crit Care Med. 1996;24:1168–1172.[Medline]
  22. Cleary SC, Gustafson D, McInnes K, et al. Quality collaboratives: lessons from research. Qual Saf Health Care. 2002;11:345.[Abstract/Free Full Text]
 

Journal Club Article Discussion Points

In a journal club, research articles are reviewed and critiqued. General and specific questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice.

When critically appraising the journal club article featured in this issue, "Using Evidence and Process Improvement Strategies to Enhance Healthcare Outcomes for the Critically Ill: A Pilot Project," consider the questions and discussion points listed below.

Study Synopsis: The purpose of this study was to assess the impact of evidence-based practice protocols that target ventilator-associated pneumonia (VAP) and catheter-related bloodstream infections (CR-BSI) in the intensive care unit (ICU). Guided by change theory, this pilot study focused on creating a facility-specific protocol to address VAP and CR-BSI prevention. Staff in the medical ICU received a 1-page document detailing the evidence-based strategies. A chart of expected activities was posted in each patient’s room. Daily rounds led by the unit nursing supervisor helped to establish adherence to key project activities including head-of-bed elevation, oral care every 2 hours, turning every 2 hours, sedation vacation once every 24 hours, peptic ulcer prophylaxis, and deep vein thrombosis prophylaxis—all known by the mnemonic acronym "HOT-SPUD." Use of the strategies over a 15-month period resulted in a 46% reduction in VAP, a 78% reduction in CR-BSI, a 19% reduction in ICU length of stay, and an estimated cost savings of $1.04 to $2.3 million.

  1. Description of the Study
  2. Literature Evaluation
  3. Sample
  4. Methods and Design
  5. Results
  6. Clinical Significance

Information From the Authors: Carol Hatler, RN, PhD, lead author of this journal club article, provided additional information about the study. Dr Hatler noted that the creative mnemonic HOTSPUD proved helpful to reinforce the components of the project. She explains: "HOTSPUD was a phrase used by Sequoia Hospital in Redwood, Calif, a sister facility within our parent organization. The organization of which St. Joseph’s is a part invited workgroups from each of the 40-plus hospitals within the organization to share information and strategies that were useful in implementing the Institute for Healthcare Improvement recommendations. It was at one of the corporate-wide meetings that the mnemonic was identified. It seemed like a useful way to refer to the project, so we adopted it. The project was initiated with a potato bar luncheon and introduction of the HOTSPUD mnemonic and behavioral expectations contained in the project."

Specific strategies were used to encourage implementation of the project components and to enhance infection control practices, notes Dr Hatler, such as "increased hand hygiene surveillance, placement of waterless hand sanitizer dispensers outside each patient’s room, review/reinforcement of central venous catheter insertion procedures that included introduction of a checklist consistent with CDC [Centers for Disease Control and Prevention] guidelines, and creation of a central venous catheter insertion kit that included only those items identified in the CDC guidelines as effective."

Reinforcement was promoted by compiling and displaying participation rates of each HOTSPUD component on staff bulletin boards each month. "Education during regularly scheduled staff meetings occurred and signage outlining the expected behaviors was placed on bulletin boards within the unit," says Dr Hatler. "One-on-one education was provided for staff who were not present for earlier sessions."

Implications for Practice: According to the study results, implementation of the evidence-based practice initiatives had a significant impact on reducing infection rates and length of stay and resulted in a significant cost savings. The project components have been adopted by the other ICUs in the facility. "In addition," adds Dr Hatler, "activities addressing glucose control have been implemented, as have additional evidence-based practices related to decreasing sepsis rates. A clinical trial is being conducted by an advanced practice nurse to determine the influence of systematic oral care on VAP rates."

Dr Hatler identifies several implications for readers of the American Journal of Critical Care. "Among the critical factors in our project was the support of and clear expectations from nurse executives," she notes. "It underscored the importance of the project and defined the measures of success for staff members and for the organization as a whole. In addition, having a consistent process and a dependable leader for daily rounds was essential to the project’s success. This leader assisted staff nurses in clarifying daily goals and in problem-solving options. The rounding process focused staff members on clinical care goals and facilitated needed improvement."

Since many ICUs are targeting VAP and CR-BSI infection, the components of this study may prove beneficial for creating facility-specific initiatives to promote the use of evidence-based practices in the ICU.

Journal Club feature commentary is provided by Ruth Kleinpell.




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