As critical care physicians, we all wish to lead our ICU to better outcomes and give the highest quality care. One way to do that is being actively involved in the development of protocols and strategies to implement evidenced based medicine in our ICUs.
Why?
- The Institute of Medicine recently released “Best Care At Lower Cost: The Path to Continuously Learning Health Care In America,” which estimated that there was 750 billion dollars in non-value adding care the U.S., yet many patients were not receiving evidence based best-practices.1
- Clearly we must strive to do better than a system that depends on one doctor to remember all aspects of evidence-based care.
- Developing protocol driven actions is specifically relevant in the ICU as the patients interact with many different providers, incurring high cost and having many opportunities for errors.
Viable Solutions:
- Quality improvement projects
- Comprehensive Unit-based Safety Program (CUSP) basically eliminated central line infections using an approach that demands a workplace focused on patient safety.2
- Checklists (washing hands, sterile drapes over the entire patient, chlorhexidine antisepsis, avoiding femoral sites), active feedback on infection rates, incorporating discussion of lines on daily rounds, and giving nurses the ability in non-urgent line placements to stop the procedure if protocol was broken.
- Structural improvements
- Having a senior pharmacist on rounds decreased preventable drug errors by 65%.3
- Decreasing laboratory processing time allows greater nursing efficiency.
- Early mobilization protocols increase patient movement.4
- Electronic Medical Records (EMR): the development of order sets can incorporate evidence based practice for routine implementation on admission to the ICU.
One concern of many physicians is the loss of autonomy with protocol driven treatment. Given the complexity of ICU patients, flexibility is an important aspect of care. We must be involved in the development of these protocols in order to advocate for our patients.
Systems that mitigate patient harm as well as increase efficiency will greatly benefit our patients moving forward; we must become leaders in patient safety.
References
- Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Released September 6, 2012.
- Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006;355:2725-32.
- Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282:267-70.
- Zomorodi M, Topley D, McAnaw M. Developing a mobility protocol for early mobilization of patients in a surgical/trauma ICU. Crit Care Res Pract. 2012;2012:964547.
