Elsevier

Journal of Critical Care

Volume 25, Issue 4, December 2010, Pages 610-619
Journal of Critical Care

ICU
The availability of clinical protocols in US teaching intensive care units

https://doi.org/10.1016/j.jcrc.2010.02.014Get rights and content

Abstract

Purpose

Clinical protocols to standardize care may improve patient outcomes but worsen trainee education. Our objective was to determine the availability of clinical protocols in teaching medical intensive care units (ICUs).

Materials and Methods

We administered an electronic questionnaire regarding protocol availability in 5 specific clinical areas. All directors of adult medical ICUs in US teaching hospitals were eligible to participate.

Results

The response rate was 70%. Eighty-six percent of ICU directors reported availability of protocols for ventilation liberation, 73% for sedation, 62% for sepsis resuscitation, 60% for lung-protective ventilation, and 48% for life support withdrawal. Ventilation liberation protocols are most often started and driven by respiratory therapists (40% and 90%); sedation started by residents (41%) and driven by nurses (95%); sepsis resuscitation started and driven by residents (49% and 46%); lung-protective ventilation started by attending physicians (39%) and driven by respiratory therapists (67%); and life support withdrawal started by attending physicians (93%) and driven by nurses (47%).

Conclusions

There is wide variation in clinical protocol availability among teaching hospitals. Further study of the effect of protocols on education is needed.

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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