New horizons (Baltimore, Md.)最新文献

There is a growing recognition that clinical research needs to define and focus on the outcomes of medical care which are important to patients. The outcomes important to patients have been coined "patient-centered" outcomes. In the past, clinical research in critical care medicine has tended to focus on survival and physiologic impairment, and not as much on outcomes such as functional status and quality of life. While survival and physiologic impairment are the appropriate outcomes in some settings, we also need to address important questions about the effect of critical care medicine on other outcomes. The goals of this article are to describe the patient-centered outcomes of critical care research, to identify important issues and pitfalls in measuring these outcomes, and to identify the situations in which these outcomes may be more or less important. The outcomes addressed include: mortality, patient-assessed outcomes (quality of life, functional status, and health status), physiologic parameters, process-of-care measures, and quality of death.

Using the scientific method, continuous improvement strives to attain unprecedented levels of performance - improved patient outcomes while maintaining or reducing costs. The needs for, and benefits of, continuous improvement are discussed along with a description of its basic elements. The approaches outlined can serve to greatly increase the pace of improvement in health care.

With the technology explosion and scientific advances in the field of critical care in the past three decades came an era in which ICUs were referred to as an arena for punitive survivalists. Although clinicians have developed an increased ability to improve the quality and quantity of life for patients in the long term post discharge, patients and their families often suffered more than is necessary in the short term, during the critical care phase of the illness. It is well documented that physiologic and psychologic stress impacts negatively on both short-term and long-term patient outcomes. In the last 10 yrs, the attention of individual caregivers, units, organizations, and researchers has turned to improving the ICU experience for patients and families. This article reviews the relevant literature and also reports the experience of those who have created and applied unique strategies that address the patient and family needs, thus promoting their comfort and relieving their distress. Although more outcome studies are needed in this area of care, applying some of the lessons already learned can significantly improve the ICU experience for most patients and families.

Technology utilization in acute and critical care holds great promise for improving the management and outcome of patients. However, before this promise can be realized, technology has to be properly evaluated for appropriateness of use. This evaluation must include both the clinical impact on patient outcomes as well as the economic impact. Following this initial evaluation, for technologies deemed appropriate for use, careful preparation of clinicians in the use of the technology is necessary. Education must prioritize how the technology is to be used as well as provide incentives for the clinicians to change their current practice. If these three key steps are followed, technology can achieve the promise of improving patient management and outcome. Unfortunately, evidence exists which suggests that these three steps are not followed in many, if not most, hospitals in the United States. In this article, a method of implementing these three steps is presented. However, it is essential that national organizations and societies become active in this process, lest widespread variation in technology utilization continue.

Mechanical ventilation is one of the most common medical therapies administered within ICUs. Similarly, the "weaning" or "liberation" of patients from mechanical ventilation is a common and extremely important task performed in ICUs and specialized ventilator units within hospitals. Various methods exist for assessing a patient's readiness to be liberated from mechanical ventilation and for conducting the weaning process. Clinicians working in ICUs frequently develop their own personal preferences regarding the best approach to weaning patients from ventilatory support. Therefore, variability in the practice of weaning patients from mechanical ventilation is frequently demonstrated, even within a single ICU. Recently, several randomized clinical trials have produced conflicting results regarding the best technique for carrying out the weaning process (e.g., spontaneous breathing trials, intermittent mandatory ventilation, pressure-support ventilation). Such conflicting findings have further illustrated the complexity of the weaning process and the difficulties in identifying the "best" medical practices for carrying out this endeavor. However, other investigations have suggested that the selection of an individual technique for weaning patients from mechanical ventilation may not be as important as employing a systematic approach to this medical process. Protocol-guided weaning of mechanical ventilation in the ICU setting, often performed by nonphysicians, has gained in acceptance as a result of these investigations. We describe the recent experiences of three ICUs which have demonstrated significant improvements in patient outcomes (e.g., shorter durations of mechanical ventilation, lower incidence of ventilator-associated pneumonia, fewer patient complications) as a result of implementing formal weaning protocols. Our hope is that these data will assist other hospitals in developing their own systematic guidelines and protocols for weaning patients from mechanical ventilation.

The practice of medicine is shaped by prior experiences. I believe that "outcomes research" involves studies that answer questions you need to resolve in order to more effectively practice medicine. Review of the outcomes of interventions is required to assess the effectiveness of our interventions. The major management problem of blood and marrow transplantation (BMT) recipients is the overwhelmingly high mortality with critical illness. A series of studies about these outcomes forms the basis of the present management strategies and decision-making after BMT. The questions involve survival after life support and the ability to identify survivors and nonsurvivors preemptively. The incidence of mechanical ventilation is associated with the characteristics of the recipients. Older age, receipt of an HLA-nonidentical graft, and malignancy in relapse at time of transplantation are associated with respiratory failure. These data are of limited value in predicting survival. It is extremely difficult to identify the small percentage of patients who will survive these episodes. However, experience suggests that patients can be identified who will not survive. Preliminary evidence suggests that physicians do not effectively utilize this mortality data in decisions about withdrawal of life support.

Significant variation from physician to physician and from hospital to hospital occurs in the management of pneumonia, despite nearly identical patient populations and causative organisms. This situation seems ideal for the use of clinical practice guidelines (CPGs), and several have already been published. The underlying assumptions used to develop pneumonia CPGs need to be examined before further proliferation of pneumonia CPGs. Some issues with pneumonia CPGs are common to all CPGs including the need for validation, especially on a local basis, and the reluctance of practitioners to follow CPGs. Need to adjust antibiotic recommendations based on emerging antibiotic resistance is common to all CPGs for infectious problems. The ability of currently available pneumonia CPGs to affect outcome is suspect because most of the recommendations rely on data that were not outcome-based. Aspects of current pneumonia CPGs are reviewed based on subsequently available data which either validate or question the recommendations.

The ICU, perhaps more than any other area in modern medicine, brings the conflicting issues of high cost and life-saving technology into stark relief. Cost-effectiveness analysis offers a quantitative method for selecting among treatments to optimize outcomes for any given financial outlay. Impediments to developing and using cost-effectiveness analysis to guide medical care decisions include the lack of accurate estimates or treatment effectiveness and reliable cost measures; variations in assumptions used in different cost-effectiveness analyses; and lack of an ethical or regulatory construct to ensure that the decisions will be carried out fairly. Recently, standards for performing cost-effectiveness analyses have been proposed which should enhance the quality and comparability of studies. A detailed understanding of the methods and limitations of economic analyses is essential to clinicians challenged by a growing number of articles and manufacturers' claims regarding the cost-effectiveness of critical care.

The impact of respiratory care practitioners on the outcomes of critically ill patients has not been examined in a systematic manner. This is in contrast to clinical investigations which have demonstrated the beneficial influence of specially trained critical care physicians and nurses on patient outcomes in the ICU setting. Outcomes research represents a method for the formal evaluation of various healthcare provider staffing patterns within the ICU. Specific patient outcomes including hospital mortality, respiratory complications, lengths of stay, and medical care costs can be used to determine the optimal ICU staffing strategy for respiratory care practitioners. Until recently, we have lacked good outcomes data for assessing the role of respiratory care practitioners in the ICU. Several barriers have contributed to this deficiency of data including a lack of funding, absence of a national research initiative aimed at this specific issue, and the paucity of clinical investigators in this area of study. Good outcomes research requires appropriate levels of funding, adequately trained and experienced clinical investigators from various disciplines (e.g., statistics, epidemiology, general medical sciences), and the support of both local and national organizations with an interest in respiratory care services and their impact on patient outcomes. To accomplish these research goals, an organized and dedicated approach must be developed based upon strong research proposals. This will allow advances to be made in the area of outcomes research as it relates to the role of respiratory care practitioners in the ICU. Similarly, the methods of outcomes research can be employed to better define the benefits and limitations of other ICU practices.