RT Journal Article SR Electronic T1 Impact of audit and feedback with action implementation toolbox on improving ICU pain management: cluster-randomised controlled trial JF BMJ Quality & Safety JO BMJ Qual Saf FD BMJ Publishing Group Ltd SP 1007 OP 1015 DO 10.1136/bmjqs-2019-009588 VO 28 IS 12 A1 Roos-Blom, Marie-José A1 Gude, Wouter T A1 de Jonge, Evert A1 Spijkstra, Jan Jaap A1 van der Veer, Sabine N A1 Peek, Niels A1 Dongelmans, Dave A A1 de Keizer, Nicolette F YR 2019 UL http://qualitysafety.bmj.com/content/28/12/1007.abstract AB Background Audit and feedback (A&F) enjoys widespread use, but often achieves only marginal improvements in care. Providing recipients of A&F with suggested actions to overcome barriers (action implementation toolbox) may increase effectiveness.Objective To assess the impact of adding an action implementation toolbox to an electronic A&F intervention targeting quality of pain management in intensive care units (ICUs).Trial design Two-armed cluster-randomised controlled trial. Randomisation was computer generated, with allocation concealment by a researcher, unaffiliated with the study. Investigators were not blinded to the group assignment of an ICU.Participants Twenty-one Dutch ICUs and patients eligible for pain measurement.Interventions Feedback-only versus feedback with action implementation toolbox.Outcome Proportion of patient-shift observations where pain management was adequate; composed by two process (measuring pain at least once per patient in each shift; re-measuring unacceptable pain scores within 1 hour) and two outcome indicators (acceptable pain scores; unacceptable pain scores normalised within 1 hour).Results 21 ICUs (feedback-only n=11; feedback-with-toolbox n=10) with a total of 253 530 patient-shift observations were analysed. We found absolute improvement on adequate pain management in the feedback-with-toolbox group (14.8%; 95% CI 14.0% to 15.5%) and the feedback-only group (4.8%; 95% CI 4.2% to 5.5%). Improvement was limited to the two process indicators. The feedback-with-toolbox group achieved larger effects than the feedback-only group both on the composite adequate pain management (p<0.05) and on measuring pain each shift (p<0.001). No important adverse effects have occurred.Conclusion Feedback with toolbox improved the number of shifts where patients received adequate pain management compared with feedback alone, but only in process and not outcome indicators.Trial registration number NCT02922101.