- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04187534
Critical Care OptimizatIon of Albumin Ordering (RATIONALE)
Critical Care Optimization of Albumin Ordering
Strong evidence suggests that human albumin solutions should not be used for fluid resuscitation except among patients undergoing therapeutic plasmapheresis and select patients with complications of liver cirrhosis (i.e. spontaneous bacterial peritonitis, or large volume ascitic fluid removal). Previous work by the investigators reported albumin use outside these circumstances as a quality improvement opportunity in Alberta ICUs. In 2017, the investigators began a pilot initiative to reduce albumin overuse in 6 ICUs in Alberta. The intervention was developed according to the Theoretical Domains Framework, and consisted of establishing a clinical champion, educating clinicians, changing the process for albumin ordering (albumin-specific order sheet), and providing quarterly audit/feedback data to clinicians on albumin utilization. During the intervention, there was a 41% relative reduction in albumin utilization. However, follow-up data identified problems with sustainability. These sustainability challenges combined with data suggesting high albumin use in other ICUs throughout Alberta have led the current project to build on the pilot initiative to reduce albumin overuse within all adult ICUs in Alberta.
The proposed quality improvement intervention will be implemented in 16 adult ICUs using a registry-based, stepped-wedge implementation design that will lean heavily on existing Provincial healthcare infrastructure. The intervention was developed using the Theoretical Domains Framework, and tailored to the unique features of each participating ICU. It will be implemented at the level of ICU. Clusters of 2 ICUs will be assigned to receive the intervention every month such that all ICUs in Alberta will receive the intervention by the end of the implementation period. To evaluate the quality improvement initiative, eCritical will serve as a 'registry' and will be used to capture all clinical and outcome data. The primary outcome will be the proportion of ICU admissions without an evidence-based indication for albumin, prescribed at least 1 unit of albumin (any concentration) during admission to ICU. 'Evidence-based indication' will be operationally defined as receipt of therapeutic plasmapheresis OR having a diagnosis of liver cirrhosis and being in receipt of a paracentesis. This latter criterion enables identification of patients with spontaneous bacterial peritonitis or large volume ascitic fluid removal.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
BACKGROUND: Strong evidence suggests that human albumin solutions should not be used for fluid resuscitation except among patients undergoing therapeutic plasmapheresis and select patients with complications of liver cirrhosis (i.e. spontaneous bacterial peritonitis, or large volume ascitic fluid removal). Previous work by the investigators reported overuse of albumin fluid resuscitation as a stakeholder-identified quality improvement opportunity in Alberta ICUs. Audit data from the provincial electronic medical record (EMR) for critical care, eCritical, reinforced stakeholder opinion and demonstrated that within Alberta ICUs in 2016 a considerable amount of albumin use deviated from evidence-based indications. On average, 14% of admissions to adult ICUs received at least one albumin unit during their ICU admission, with several high-use units providing albumin to between 20% and 35% of admissions. In 2017 the investigators began a pilot quality improvement initiative to reduce albumin overuse in six ICUs in Alberta. The intervention was developed according to the Theoretical Domains Framework. Questionnaires completed by clinicians working in the target ICU identified local culture and opinion of clinical leaders as barriers, and education, order sets, and clinical champions as facilitators to reducing albumin use. The intervention thus consisted of establishing a clinical champion, educating clinicians, changing the process for albumin through development of an albumin order sheet, and providing quarterly unit-level audit/feedback data to clinicians on albumin utilization. There was a 41% reduction in albumin utilization, however follow-up data identified problems with sustainability. The current project will build on the pilot initiative to implement a quality improvement intervention to reduce albumin overuse within all adult ICUs in Alberta.
OBJECTIVE: Evaluate albumin reduction within all adult ICUs in Alberta.
METHODS: This will be a registry-based, stepped-wedge quality improvement initiative.
Quality Improvement Initiative: Spread to 16 adult ICUs in Alberta will require understanding and adapting the investigators pilot intervention to local barriers and facilitators. The intervention for this quality improvement initiative will be developed using the Theoretical Domains Framework. The research team will develop working groups responsible for tailoring the intervention and implementation strategy to each participating ICU. This will be conducted as part of the Province-wide quality improvement initiative. The investigators will conduct the quality improvement initiative using a registry-based, stepped-wedge, implementation trial. Owing to the nature of this design, the interventions will be implemented at the level of ICU. Clusters of 2 ICUs will be assigned to receive the intervention every month such that all ICUs in Alberta will receive the intervention by the end of the implementation period.
Registry-based data analysis: To evaluate this quality improvement initiative, the Provincial EMR for critical care, eCritical, will serve as a 'registry' and will be used to capture all clinical and outcome data. Data will be collected until patient death or hospital discharge and censored at 60 days. To optimize efficiency and power, data will be collected 3-months before and after implementation of the interventions.
SETTING: 16 adult ICUs in Alberta's critical care strategic clinical network reflecting teaching/non-teaching and urban/rural hospitals will participate.
STUDY POPULATION: All adult patients (>18 years) admitted to the study ICUs during the study period (November 2019 to January 2021). Study ICUs will include 14 general medical-surgical ICUs, and 2 cardiovascular surgery ICUs.
OUTCOMES: The primary outcome of this study will be the proportion of ICU patients without an evidence-based indication for albumin prescribed at least 1 unit of albumin (any concentration) during admission to ICU. Evidence-based indication will be operationally defined as receipt of therapeutic plasmapheresis OR having a diagnosis of liver cirrhosis and being in receipt of a paracentesis. This latter criterion enables identification of patients with either spontaneous bacterial peritonitis or large volume ascitic fluid removal. This outcome was selected because: 1) there is precedent within current literature; 2) previous experience auditing albumin utilization in Alberta ICUs demonstrate it is available through eCritical; 3) it provides a relevant, broadly understandable estimate of the effect of the implementation science intervention to change albumin overuse; and 4) it permits assessment of the feasibility of implementing the platform to develop and carry out multi-stakeholder implementation science interventions to promote evidence-informed clinical practices and evaluate the intervention.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
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Alberta
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Calgary, Alberta, Canada, T2N 2T9
- Foothills Medical Centre
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Calgary, Alberta, Canada, T1Y 6J4
- Peter Lougheed Centre
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Calgary, Alberta, Canada, T2V 1P9
- Rockyview General Hospital
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Calgary, Alberta, Canada, T3M 1M4
- South Health Campus
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Edmonton, Alberta, Canada, T6G 2B7
- University of Alberta Hospital
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Edmonton, Alberta, Canada, T5H 3V9
- Royal Alexandra Hospital
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Edmonton, Alberta, Canada, T5R 4H5
- Misericordia Community Hospital
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Edmonton, Alberta, Canada, T4N 4E7
- Mazankowski Heart Institute
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Edmonton, Alberta, Canada, T6L 5X8
- Grey Nun's Hospital
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Fort McMurray, Alberta, Canada, T9H 1P2
- Northern Lights Regional Health Centre
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Grande Prairie, Alberta, Canada, T8V 2E8
- Queen Elizabeth II Hospital
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Lethbridge, Alberta, Canada, T1J 1W5
- Chinook Regional Hospital
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Medicine Hat, Alberta, Canada, T1A 4H6
- Medicine Hat Regional Hospital
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Red Deer, Alberta, Canada, T4N 4E7
- Red Deer Regional Hospital Centre
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St. Albert, Alberta, Canada, T8N 6C4
- Sturgeon Community Hospital
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- All adult patients admitted to the study ICUs
Exclusion Criteria:
-
Study Plan
How is the study designed?
Design Details
- Primary Purpose: HEALTH_SERVICES_RESEARCH
- Allocation: NON_RANDOMIZED
- Interventional Model: SEQUENTIAL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
EXPERIMENTAL: Albumin Fluid Resuscitation Optimization Intervention
Our quality improvement intervention seeking to improve appropriate use and reduce inappropriate use of albumin for fluid resuscitation will consist of establishing a clinical champion, educating clinicians, changing the process for albumin ordering through development of an albumin order sheet, and providing quarterly unit-level audit/feedback data to clinicians on albumin utilization.
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Multi-faceted quality improvement intervention to optimize appropriateness of albumin use for fluid resuscitation
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ACTIVE_COMPARATOR: Usual Practice
Stepped-wedge roll out of 'Albumin Fluid Resuscitation Optimization Intervention' will permit those ICUs wherein intervention has not yet been implemented to serve as controls.
These ICUs will prescribe albumin according to usual practice and not be exposed to any components of the intervention.
|
Albumin fluid resuscitation according to usual practice
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Proportion of ICU admissions receiving albumin
Time Frame: During ICU admission
|
Proportion of ICU admissions without an evidence-based indication for albumin prescribed at least 1 unit of albumin (any concentration) during admission to ICU
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During ICU admission
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Mean number of albumin units among those receiving albumin
Time Frame: During ICU admission
|
Mean number of albumin units prescribed to patients without an evidence-based indication for albumin that received at least 1 unit of albumin
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During ICU admission
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Total fluid administration
Time Frame: ICU day 7
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Total volume of fluid administered during days 1-7 in ICU
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ICU day 7
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Total crystalloid fluid
Time Frame: ICU Day 7
|
Total volume of crystalloid fluid administered during days 1-7 in ICU
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ICU Day 7
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Duration of vasopressor administration
Time Frame: From date of ICU admission to date of discharge, on average 1-6 days
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Number of days vasopressors administered during ICU length of stay
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From date of ICU admission to date of discharge, on average 1-6 days
|
Length of mechanical ventilation
Time Frame: From date mechanical ventilation commended to date discontinued, on average 0-3 days
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Number of days on mechanical ventilation from time of starting mechanical ventilation during ICU length of stay
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From date mechanical ventilation commended to date discontinued, on average 0-3 days
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ICU length of stay
Time Frame: From date of ICU admission to date of discharge, on average 1-6 days
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Number of days admitted to ICU (unique number per admission)
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From date of ICU admission to date of discharge, on average 1-6 days
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Hospital length of stay
Time Frame: From date of hospital admission to date of discharge, on average 5-20 days
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Number of days admitted to hospital (unique number per admission)
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From date of hospital admission to date of discharge, on average 5-20 days
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ICU mortality
Time Frame: From date of ICU admission to date of discharge, on average 1-6 days
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Survival to discharge from ICU
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From date of ICU admission to date of discharge, on average 1-6 days
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Hospital mortality
Time Frame: From date of hospital admission to date of discharge, on average 5-20 days
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Survival to discharge from hospital
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From date of hospital admission to date of discharge, on average 5-20 days
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Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Daniel J Niven, MD, PhD, University of Calgary
Publications and helpful links
Study record dates
Study Major Dates
Study Start (ACTUAL)
Primary Completion (ACTUAL)
Study Completion (ACTUAL)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ACTUAL)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 19-1143
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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