New horizons (Baltimore, Md.)
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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. ⋯ 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.
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Review
Improving end-of-life care in the intensive care unit: what's to be learned from outcomes research?
Current recommendations about the care of dying patients advise that healthcare professionals understand and respect the goals, priorities, needs, and suffering of each dying patient and have command of the skills and resources required to address these concerns. Studies of important features of terminal illness, current use and outcome of intensive care for the terminally ill, and interventions designed to improve the outcome of care for patients who die in ICUs are reviewed to examine discrepancies between recommendations and the reality of ICU care for dying patients. Evidence indicates that it is difficult to predict the time of death or determine patient preferences about treatment prior to death. ⋯ The largest interventional study, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), which provided physicians with information about patient prognosis and preferences for care, did not alter outcomes of end-of-life care. Smaller but successful interventional studies have included examination of an alternative team that provides care tailored to the needs of dying patients, a service tailored to promote family contact with the dying patient, and proactive consultation to facilitate care planning and communication with families. Research suggests that clinicians should be cognizant of the difficulty of predicting death and anticipate the need to change the goals of care as therapeutic trials fail; anticipate and treat bothersome symptoms of dying patients; recognize that family support and contact between the dying patient and family facilitate decision-making and acceptance of death; and facilitate the coordination of care and the development of alternative care teams in order to optimize end-of-life care.
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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. ⋯ 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.
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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. ⋯ 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.
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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. ⋯ 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.