Abstract：
National Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety.
Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care.
Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: \'discharge from recovery room\' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - \'discharge from the hospital\' - possibly because of the limited resources of hospitals to improve all stop moments together.
Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics.
NTR3568 (Dutch Trial Registry).
Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care.
Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: \'discharge from recovery room\' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - \'discharge from the hospital\' - possibly because of the limited resources of hospitals to improve all stop moments together.
Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics.
NTR3568 (Dutch Trial Registry).
摘要：
荷兰国家指南已被引入以改善不良的围手术期护理。已制定了多方面的实施计划（IMPlementatieRichtlijnenOperatieveVEiligheid[改善]），以支持医院应用这些指南。这项研究评估了IMPROVE对指南依从性的有效性以及指南依从性与患者安全性之间的关联。
九家医院参与了这场脱盲，优越性,阶梯式楔形，大型非心脏手术患者的成簇RCT（死亡风险≥1％）。改进包括教育活动，审计和反馈，提醒,组织,团队指导,和患者介导的活动。该研究的主要结果是通过九项患者安全指标衡量的指南依从性（来自复合STOP束的停止时刻，并及时使用抗生素）以及围手术期护理的结构。次要安全性结果包括院内并发症，术后伤口感染，死亡率,住院时间,计划外的照顾。
分析了1934例患者的数据。IMPROVE程序改进了一个停止时刻：\'从恢复室出院\'（+16%；95%置信区间[CI]，9-23%）。此停止时刻与死亡率降低有关（-3％；95％CI，-4％至-1％），并发症较少（-8%；95%CI，-13%至-3%），更少的计划外转移到ICU（-6％；95％CI，-9％至-3％）。改善另一个停止时刻的负面影响-\“出院”-可能是因为医院的资源有限，以改善所有停止时刻。
发现了IMPROVE的混合实施效果。我们发现指南依从性和患者安全(即死亡率，并发症,和计划外转移到ICU），但及时使用抗生素除外。
NTR3568（荷兰审判登记处）。
九家医院参与了这场脱盲，优越性,阶梯式楔形，大型非心脏手术患者的成簇RCT（死亡风险≥1％）。改进包括教育活动，审计和反馈，提醒,组织,团队指导,和患者介导的活动。该研究的主要结果是通过九项患者安全指标衡量的指南依从性（来自复合STOP束的停止时刻，并及时使用抗生素）以及围手术期护理的结构。次要安全性结果包括院内并发症，术后伤口感染，死亡率,住院时间,计划外的照顾。
分析了1934例患者的数据。IMPROVE程序改进了一个停止时刻：\'从恢复室出院\'（+16%；95%置信区间[CI]，9-23%）。此停止时刻与死亡率降低有关（-3％；95％CI，-4％至-1％），并发症较少（-8%；95%CI，-13%至-3%），更少的计划外转移到ICU（-6％；95％CI，-9％至-3％）。改善另一个停止时刻的负面影响-\“出院”-可能是因为医院的资源有限，以改善所有停止时刻。
发现了IMPROVE的混合实施效果。我们发现指南依从性和患者安全(即死亡率，并发症,和计划外转移到ICU），但及时使用抗生素除外。
NTR3568（荷兰审判登记处）。
