New horizons (Baltimore, Md.)
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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.
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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. ⋯ 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.
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Review
Making changes to improve the intensive care unit experience for patients and their families.
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. ⋯ 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.