Standardized intensive care: Protocol misalignment and impact misattribution

American Journal of Respiratory and Critical Care Medicine

Volumn 193, Issue 1, 2016, Pages 17-22

  Kavanagh, Brian P ^a   Nurok, Michael ^b  

^a HOSPITAL FOR SICK CHILDREN   (Canada)

^b CEDARS SINAI MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL PROTOCOL; CLINICAL RESEARCH; HUMAN; INTENSIVE CARE; PERIOPERATIVE PERIOD; PRACTICE GUIDELINE; PRIORITY JOURNAL; REVIEW; SEPSIS; STANDARDIZATION; ADVERSE EFFECTS; PATIENT HARM; STANDARDS; TOTAL QUALITY MANAGEMENT;

CLINICAL PROTOCOLS; CRITICAL CARE; HUMANS; PATIENT HARM; PERIOPERATIVE CARE; PRACTICE GUIDELINES AS TOPIC; QUALITY IMPROVEMENT; SEPSIS;

EID: 84973409435     PISSN: 1073449X     EISSN: 15354970     Source Type: Journal    
DOI: 10.1164/rccm.201502-0314CP     Document Type: Review

References (41)

1. Carter A. Clinical practice guidelines. CMAJ 1992;147:1649-1650.
2. Tonelli MR, Curtis JR, Guntupalli KK, Rubenfeld GD, Arroliga AC, Brochard L, Douglas IS, Gutterman DD, Hall JR, Kavanagh BP, et al.; ACCP/ATS/SCCM Working Group. An official multi-society statement: the role of clinical research results in the practice of critical care medicine. Am J Respir Crit Care Med 2012;185:1117-1124.
3. Sevransky JE, Checkley W, Herrera P, Pickering BW, Barr J, Brown SM, Chang SY, Chong D, Kaufman D, Fremont RD, et al.; United States Critical Illness and Injury Trials Group-Critical Illness Outcomes Study Investigators. Protocols and hospital mortality in critically ill patients: the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med 2015;43:2076-2084.
4. Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings-limited evidence of effectiveness. BMC Health Serv Res 2011;11:211.
5. Morgan L, Hadi M, Pickering S, Robertson E, Griffin D, Collins G, Rivero-Arias O, Catchpole K, McCulloch P, New S. The effect of teamwork training on team performance and clinical outcome in elective orthopaedic surgery: a controlled interrupted time series study. BMJ Open 2015;5:e006216.
6. Doig GS, Simpson F, Finfer S, Delaney A, Davies AR, Mitchell I, Dobb G; Nutrition Guidelines Investigators of the ANZICS Clinical Trials Group. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA 2008;300: 2731-2741.
7. Polgreen PM, Chen YY, Cavanaugh JE, Ward M, Coffman S, Hornick DB, Diekema DJ, Herwaldt LA. An outbreak of severe Clostridium difficile-associated disease possibly related to inappropriate antimicrobial therapy for community-acquired pneumonia. Infect Control Hosp Epidemiol 2007;28:212-214.
8. Kett DH, Cano E, Quartin AA, Mangino JE, Zervos MJ, Peyrani P, Cely CM, Ford KD, Scerpella EG, Ramirez JA; Improving Medicine through Pathway Assessment of Critical Therapy of Hospital-Acquired Pneumonia (IMPACT-HAP) Investigators. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study. Lancet Infect Dis 2011;11:181-189.
9. Sinuff T, Cook DJ, Randall J, Allen CJ. Evaluation of a practice guideline for noninvasive positive-pressure ventilation for acute respiratory failure. Chest 2003;123:2062-2073.
10. Hill NS. Practice guidelines for noninvasive positive-pressure ventilation: help or hindrance? Chest 2003;123:1784-1786.
11. Classen DC, Mermel LA. Specialty society clinical practice guidelines: time for evolution or revolution? JAMA 2015;314: 871-872.
12. Sheares BJ, Mellins RB, Dimango E, Serebrisky D, Zhang Y, Bye MR, Dovey ME, Nachman S, Hutchinson V, Evans D. Do patients of subspecialist physicians benefit from written asthma action plans? Am J Respir Crit Care Med 2015;191:1374-1383.
13. Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, et al.; FEAST Trial Group. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483-2495.
14. Andrews B, Muchemwa L, Kelly P, Lakhi S, Heimburger DC, Bernard GR. Simplified severe sepsis protocol: a randomized controlled trial of modified early goal-directed therapy in Zambia. Crit Care Med 2014;42:2315-2324.
15. Goepfert MS, Richter HP, Zu Eulenburg C, Gruetzmacher J, Rafflenbeul E, Roeher K, von Sandersleben A, Diedrichs S, Reichenspurner H, Goetz AE, et al. Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: a prospective, randomized controlled trial. Anesthesiology 2013;119: 824-836.
16. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR; Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000;356:1375-1383.
17. Hogle KL, Kilburn L, Hewson S, Gafni A, Wall R, Hannah ME. Impact of the International Term Breech Trial on clinical practice and concerns: a survey of centre collaborators. J Obstet Gynaecol Can 2003;25: 14-16.
18. Glezerman M. Five years to the Term Breech Trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006;194: 20-25.
19. Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, Bréart G; PREMODA Study Group. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002-1011.
20. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol 2006;108:235-237.
21. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345:1359-1367.
22. Kavanagh BP. Glucose in the ICU-evidence, guidelines, and outcomes. N Engl J Med 2012;367:1259-1260.
23. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, et al.; NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-1297.
24. Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 1991;75:731-739.
25. Laffey JG, Kavanagh BP. Hypocapnia [review]. N Engl J Med 2002;347: 43-53.
26. Kavanagh BP, McCowen KC. Clinical practice: glycemic control in the ICU. N Engl J Med 2010;363:2540-2546.
27. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-2732.
28. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360:491-499.
29. Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, Ibáñez J, Palencia E, Quintana M, de la Torre-Prados MV; Edusepsis Study Group. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008;299:2294-2303.
30. Ioannidis JP. Why most published research findings are false. PLoS Med 2005;2:e124.
31. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, et al.; International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Japanese Association for Acute Medicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society of Hospital Medicine; Surgical Infection Society; World Federation of Societies of Intensive and Critical Care Medicine. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296-327.
32. Kahn JM, Bates DW. Improving sepsis care: the road ahead. JAMA 2008;299:2322-2323.
33. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011;89:167-205.
34. Bion J, Richardson A, Hibbert P, Beer J, Abrusci T, McCutcheon M, Cassidy J, Eddleston J, Gunning K, Bellingan G, et al.; Matching Michigan Collaboration & Writing Committee. ?Matching Michigan?: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf 2013;22:110-123.
35. Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014;370:1029-1038.
36. Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med 2008;168:351-356.
37. Larson DM, Menssen KM, Sharkey SW, Duval S, Schwartz RS, Harris J, Meland JT, Unger BT, Henry TD. ?False-positive? cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA 2007;298: 2754-2760.
38. New York State Department of Health. Hospital sepsis protocols. 2013 May 1 [accessed 2015 Oct 3]. Available from: http://www.health.ny.gov/regulations/recently-adopted/docs/2013-05-01-hospital-sepsis-protocols.pdf.
39. Jacobson PD. Transforming clinical practice guidelines into legislative mandates: proceed with abundant caution. JAMA 2008;299: 208-210.
40. Tobin MJ. Of principles and protocols and weaning. Am J Respir Crit Care Med 2004;169:661-662.
41. Mohr NM, Collier J, Hassebroek E, Groth H. Characterizing critical care physician staffing in rural America: a description of Iowa intensive care unit staffing. J Crit Care 2014;29:194-198.