ICUThe availability of clinical protocols in US teaching intensive care units
Introduction
Clinical protocols are formal pathways with specific inclusion and exclusion criteria that provide standardized algorithms for caring for patients with specific conditions. Protocols are commonly used to help implement evidence-based therapies and reduce unnecessary practice variation in the intensive care unit (ICU). Some evidence suggests that protocol use is associated with improved patient-centered outcomes, especially in the areas of sedative administration and weaning from mechanical ventilation [1], [2], [3]. As a result, many international professional societies promote the use of clinical protocols in their campaigns to improve the quality of critical care [4]. However, the overall benefits of routine protocol use in the ICU are still widely debated [5]. Proponents argue that protocols help to standardize care and improve patient outcomes by facilitating evidence-based practice [3], [6], [7]. Opponents argue that protocols discourage clinical reasoning resulting in what is sometimes called “cookbook medicine” [8], [9] and note that protocols are not consistently associated with improved patient outcomes in all studies [7].
In addition, some individuals express concern about the impact of protocol use on the training of new physicians. Practice-based learning is a core tenet of medical education. By creating a disconnect between trainees and the patient, protocols may rob trainees of important clinical experiences and thus impair acquisition of new skills [10]. Protocols may also prevent trainees from seeking assistance from senior physicians about complex management issues, eliminating an opportunity for supervised education. Although one study showed no difference in trainee performance on standardizing questions about respiratory care whether or not they trained in an institution with respiratory protocols [11], the overall effect of protocols on medical education is as yet unknown.
A first step to understanding the potential impact of clinical protocols on ICU education is to understand the prevalence of protocol availability in teaching ICUs and the ways in which these protocols are used in daily practice. The purpose of this study was to determine the availability of clinical protocols in medical ICUs of US teaching hospitals and the hospital and ICU characteristics associated with their use. To do so, we conducted a nationwide survey of medical directors of teaching medical ICUs regarding their use of clinical protocols.
Section snippets
Study design and population
We performed an Internet-based survey of directors of adult medical ICUs in US teaching hospitals. All 129 primary training sites for accredited US pulmonary and critical care fellowship programs in 2008 were eligible to participate. We specifically selected the ICUs of fellowship training programs because these ICUs are most likely to have a strong educational mission and highly prioritize evidenced-based practice and training. We obtained a list of all training programs from the Web site of
Results
A total of 90 ICU directors responded to the survey (final response rate: 70%). Hospitals represented by respondents (n = 90) were similar to those of nonrespondents (n = 39). Most hospitals in both groups had greater than 250 beds (97% of respondents and 95% of nonrespondents); were private, or nonprofit, or government hospitals (95% and 98%); and were medical school affiliated (96% and 100%). Similar proportions were high-intensity teaching hospitals, with resident/bed ratios of more than 0.6
Discussion
In a national survey of academic medical ICU directors, we found wide variation in the stated number, types, and clinical area of protocols available for the care of critically ill adults. Furthermore, in those protocols that are available, variation exists in their content and structure, even for protocols supported by well-developed medical evidence. Specifically, the providers that start and drive the protocols vary widely, both within and among the different content areas.
Our results have
Conclusions
There is variation in the availability, content, and structure of clinical protocols in teaching medical ICUs, even in content areas with well-accepted evidence where standardized care may be appropriate. The reasons for these variations are unclear, and the best use of clinical protocols is still controversial. Further research is needed to better understand the impact of protocols on patient outcomes and medical education and to understand how we may use clinical protocols to balance the
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2021, Journal of Surgical ResearchCitation Excerpt :One strategy used to reduce variation and improve quality is the use of protocols, guidelines, checklists, pathways, and algorithms (hereafter collectively referred to as protocols).4,5 Many surgery and trauma organizations have disseminated these tools,6-8 and their use is common in critical care.9,10 Some protocols are based on high quality research that demonstrates improved patient outcomes or supports the superiority of one treatment strategy over another,11 whereas others only seek to promote uniformity of practice through reducing variation with the system of care.12
Is there a better way to deliver optimal critical care services?
2019, Evidence-Based Practice of Critical CareDo protocols/guidelines actually improve outcomes?
2019, Evidence-Based Practice of Critical CarePalliative and end-of-life educational practices in US pulmonary and critical care training programs
2016, Journal of Critical CareCitation Excerpt :The highest degree of competence and comfort was reported in managing withdrawal from mechanical ventilation. This may be due to trainees' interest and facility in technical ventilator skills, as well as the fact that half of ICU training programs have protocolized orders to guide ventilator withdrawal [15]. In contrast, trainee comfort level was lowest in the use of institutional and community resources.
Variation in tracheal reintubations among patients undergoing cardiac surgery across washington state hospitals
2015, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :The ability to risk-stratify patients at high risk for extubation failure and implement evidence-based measures to optimize and standardize care, potentially also may improve patient safety and reduce the incidence of reintubation.39,40 Protocol use is variable across teaching ICUs in Washington state41 and higher volume hospitals have been shown to be associated with higher-quality protocols and improved outcomes.8,14 Improving the quality of ICU extubation protocols might lead to better extubation outcomes.