What to do when protocols fail

Respiratory Care

Volumn 52, Issue 3, 2007, Pages 324-336

  Durbin Jr , Charles G ^a  

^a UNIVERSITY OF VIRGINIA HEALTH SYSTEM   (United States)

Author keywords

Best practice; Clinical practice; Evidence based medicine; Guidelines; Protocols; Quality improvement; Respiratory care; Translational research

Indexed keywords

ACUTE LUNG INJURY; ADULT RESPIRATORY DISTRESS SYNDROME; CHRONIC OBSTRUCTIVE LUNG DISEASE; CLINICAL PROTOCOL; CONTINUING EDUCATION; DIAGNOSTIC ERROR; EVIDENCE BASED MEDICINE; HEALTH CARE DELIVERY; HEALTH CARE PLANNING; HEALTH CARE QUALITY; HEALTH PROMOTION; HUMAN; INTENSIVE CARE UNIT; MEDICAL EDUCATION; MEDICAL ERROR; MEDICAL LITERATURE; PATIENT SAFETY; PRACTICE GUIDELINE; QUALITY CONTROL; RESPIRATORY CARE; RESPIRATORY THERAPIST; REVIEW; RISK ASSESSMENT; SEPSIS; SPIROMETRY; STANDARDIZATION; TOTAL QUALITY MANAGEMENT; VENTILATOR ASSOCIATED PNEUMONIA; WORLD HEALTH ORGANIZATION; ARTICLE; MASS COMMUNICATION; SAFETY; STANDARD; UNITED STATES;

CLINICAL PROTOCOLS; DIFFUSION OF INNOVATION; PULMONARY DISEASE, CHRONIC OBSTRUCTIVE; QUALITY OF HEALTH CARE; SAFETY MANAGEMENT; UNITED STATES;

EID: 34247160514     PISSN: 00201324     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (37)

1. Corrigan J, Kohn LT, Donaldson MS, editors. To err is human: building a better health system. Washington DC: National Academies Press; 1999.
2. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press; 2001.
3. Baker JP. Magnitude of usage of intermittent positive pressure breathing. Am Rev Respir Dis 1974;110(6 Pt 2):170-177.
4. Bartlett RH, Gazzaniga AB, Geraghty TR. Respiratory maneuvers to prevent postoperative pulmonary complications: a critical review. JAMA 1973;224(7):1017-1021.
5. Indihar FJ, Forsberg DP, Adams AB. A prospective comparison of three procedures used in attempts to prevent postoperative pulmonary complications. Respir Care 1982;27(5):564-568.
6. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis 1984;130(1):12-15.
7. Browner B, Powers SR. Effect of IPPB on functional residual capacity and blood gases in postoperative patients. Surg Forum 1975;26:96-98.
8. Pierce AK, Saltzman HA (chairmen). Conference on the scientific basis of respiratory therapy. Am Rev Respir Dis 1974;110(6 Pt 2):1-204.
9. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 8: Stabilization of the patient with acute coronary syndromes. [Internet]. Available at http://circ.ahajournals.org. (Accessed Jan18, 2007)
10. Nielsen-Tietsort J, Poole B, Creagh CE, Repsher LE. Respiratory care protocol: an approach to in-hospital respiratory therapy. Respir Care 1981;26(5):430-436.
11. Beck AH. The Flexner report and the standardization of American medical education. JAMA 2004;291(17):2139-2140.
12. Flexner A. Medical education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching; 1910.
13. Claridge JA, Fabian TC. History and development of evidence-based medicine. World J Surg 2005;29(5):547-553.
14. National Guideline Clearinghouse. [Internet]. Available at http://www.guideline.gov. (Accessed Jan18, 2007)
15. Field MJ, Lohr KN, editors. Clinical practice guidelines: directions for a new program. Washington DC: National Academy Press; 1990: 38.
16. National Guideline Clearinghouse. Guideline synthesis: Chronic obstructive pulmonary disease (COPD). Part II. Diagnosis and management of acute exacerbations. In: National Guideline Clearinghouse. Rockville, Maryland; April 2006 update. Available at http://www.guideline.gov. (Accessed Dec 28, 2006)
17. Rittenberger JC, Beck PW, Paris PM. Errors of omission in the treatment of prehospital chest pain patients. Prehosp Emerg Care 2005;9(1):2-7.
18. Woollard M, Smith A, Elwood P. Pre-hospital aspirin for suspected myocardial infarction and acute coronary syndromes: a headache for paramedics? Emerg Med J 2001;18(6):478-481.
19. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342(18):1301- 1308.
20. Young MP, Manning HL, Wilson DL, Mette SA, Riker RR, Leiter JC, et al. Ventilation of patients with acute lung injury and acute respiratory distress syndrome: Has new evidence changed clinical practice? Crit Care Med 2004;32(6):1260-1265.
21. Weinert CR, Gross CR, Marinelli WA. Impact of randomized trial results on acute lung injury ventilator therapy in teaching hospitals. Am J Respir Crit Care Med 2003;167(10):1304-1309.
22. Katz DA. Barriers between guideline and improved patient care: an analysis of AHCPR's Unstable Angina Clinical Practice Guideline. Agency for Health Care Policy and Research. Health Serv Res 1999;34(1 Pt 2):377-389.
23. Sinuff T, Cook DJ. Guidelines in the intensive care unit. Clin Chest Med 2003;24(4):739-749.
24. Silagy CA, Weller DP, Lapsley H, Middleton P, Shelby-James T, Fazekas B. The effectiveness of local adaptation of nationally produced clinical practice guidelines. Fam Pract 2002;19(3):223-230.
25. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004;8(6):1-84. [Internet]. Available at http://www.ncchta.org. (Accessed Jan18, 2007)
26. Institute for Healthcare Improvement. About us. [Internet]. Available at http://www.ihi.org. (Accessed Jan18, 2007)
27. Victory Over Small Pox. World Health Organization. Available at http://www.who.int/csr/disease/smallpox/en. (Accessed January 7, 2007)
28. Centers for Medicare and Medicaid Services. National SCHIP policy. [Internet]. Available at http://www.cms.hhs.gov/NationalSCHIPPolicy. (Accessed Jan18, 2007)
29. Ibrahim EH, Tracy L, Hill C, Fraser VJ, Kollef MH. The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest 2001;120(2):555-561.
30. Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122(6):2115-2121.
31. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53(RR-3):1-36.
32. Institute for Healthcare Improvement. Implement the ventilator bundle. [Internet]. Available at http://www.ihi.org. (Accessed Jan 18, 2007)
33. Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996;335(25):1864-1869.
34. Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 1999;159(2):439-446.
35. Institute for Healthcare Improvement. Surviving sepsis campaign. Changes. [Internet]. Available at http://www.ihi.org. (Accessed Feb 5, 2007)
36. Institute for Healthcare Improvement. Implement the sepsis management bundle: Prevent excessive inspiratory plateau pressures. [Internet]. Available at http://www.ihi.org. (Accessed Jan 18, 2007)
37. Institute for Healthcare Improvement. Protecting 5 million lives from harm. [Internet]. Available at http://www.ihi.org. (Accessed Jan 18, 2007)