Purpose

To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs).

Methods

MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions’ effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesised using the Consolidated Framework for Implementation Research.

Results

78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with local systems. There was a lack of evidence from low-income countries.

Conclusions

The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.

中文翻译：

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改善低收入和中等收入国家重症监护的干预措施：系统评价

 目的

系统评价低收入和中等收入国家 (LMIC) 成人重症监护质量改进 (QI) 干预措施的类型、影响、证据质量、障碍和促进因素。

 方法

MEDLINE、EMBASE、Cochrane Library 和 ClinicalTrials.gov 于 2022 年 9 月 1 日进行了检索。如果这些研究描述了中低收入国家成人重症监护 QI 干预措施的实施情况，则这些研究将被纳入，全文为英文，并于 2000 年之后出版。使用 ROB 2.0/ROBINS-I 工具评估偏倚。干预策略根据知识翻译框架进行分类。干预措施的有效性通过计票来综合，并通过二项式检验进行评估。使用实施研究综合框架以叙述方式综合了实施的障碍和促进因素。

 结果

纳入了 78 项研究。偏见风险很高。最常见的干预策略是教育、审核和反馈 (A&F) 以及协议/指南/捆绑包/清单 (PGBC)。两项多方面策略改善了过程和结果衡量标准：教育和 A&F（p = 0.008）；以及 PGBC 与教育和 A&F（p = 0.001，p < 0.001）。实施的促进因素包括利益相关者的参与、组织实施的准备情况以及干预措施的适应性。障碍是缺乏资源以及与当地系统不兼容。缺乏来自低收入国家的证据。

 结论

中低收入国家重症监护中 QI 的证据很少，且偏倚风险很高，但表明多方面的干预措施是最有效的。与利益相关者共同设计干预措施并让利益相关者参与进来，交流相对优势，雇用当地冠军并适应反馈可以改善实施。混合研究设计、过程评估和遵守报告指南将改善证据基础。