笑看古今

晚间浏览网页，无意中发现了一篇对下面这篇文章的推荐文章，心中一动，马上找到原文读了一遍，觉得真是很不多，我把原文的讨论和结论部分摘录如下，和大家分享。

 Impact of introducing multiple evidence-based clinical practice protocols in a medical intensive care unit: a retrospective cohort study

Discussion

In this study, we found that the introduction of multiple evidence-based clinical practice protocols was associated with a decline in severity-adjusted hospital mortality. We also noted that the 28-day ICU free days improved slightly. The benefits were limited to sicker patients and those who had longer ICU stay. The study suggests that the application of multiple evidence-based clinical practice protocols improves the clinical outcome of the critically ill.Because of the complexity of intensive care units, the Institute for Healthcare Improvement (IHI) advocates use of protocol-based bundles in order to apply the best available science into clinical practice and improve patient outcome [25]. In the current study, the introduction of multiple evidence-based protocols was associated with reducing the severity-adjusted risk of hospital death.There are only few studies that addressed the impact of the application of multiple protocols on the outcome of critically ill patients. Previous studies have shown that the implementation of a ventilator bundle protocol (composed of stress ulcer prophylaxis, deep vein thrombosis prophylaxis, daily cessation of sedation and elevating the patient's head at least 30 degrees above the horizontal with or without daily assessment of readiness to wean from mechanical ventilation) reduces the ICU length of stay and duration of mechanical ventilation [13,26]. The IHI has initiated the various phases of Saving Lives Campaign. The campaign focuses on reducing mortality by implementing evidence-based practices and reducing errors. The findings in this study highlight the fact that implementation of evidence-based clinical practice protocols may help to achieve the objectives of the Saving Lives Campaign.In the Acute Respiratory Distress Syndrome Network study, lung protective strategy reduced the mortality of patients with ALI from 39.8% to 31.0% [4]. van den Berghe and colleagues showed that intensive insulin therapy reduced mortality of a predominantly surgical critically ill patient population from 10.9% to 7.2% [5]. In a recent study of medical ICU patients by the same group, the survival benefit of intensive insulin therapy was limited to patients who stay in the ICU for more than three days [6]. In the overall MICU patient population, the hospital mortality rate associated with intensive insulin therapy (37.3%) was not statistically different from that of conventional treatment (40.0%). However, in patients who stayed in the medical ICU for more than three days, intensive insulin therapy was associated with reducing the hospital mortality rate from 52.5% to 43.0% [6]. In patients with severe sepsis, recombinant human activated protein C reduced the mortality rate from 30.8% to 24.7% [7]. The reduction in mortality observed in our study is consistent with the findings from the randomized clinical trials. With regard to recombinant human activated protein C, recent observations suggest that only a minority of eligible patients receive the treatment and it may have a detrimental effect in certain subgroups of patients [27,28].The implications of reducing ICU days include reducing ICU complications and associated costs. The study by Kress and colleagues had shown reduction of ICU stay by 3.5 days using a protocol with daily interruption of sedative infusions [2]. The 28-day ICU free days were longer in the protocol period in our study by 0.7 days. With the shortage of staffed ICU beds in many medical centers, reducing the ICU length of stay has important implications, by decreasing the associated cost and avoiding delays in the care of patients waiting for ICU beds. Although we did not implement the sedation/analgesia protocol before 2004, it had been applied at the individual clinician's discretion, partly explaining why we did not see the dramatic effect reported by Kress et al. In our ICU, the critical care team made rounds at least twice daily. Even before the protocols were implemented, the critical care consultants who guided daily care and the fellows were aware of the studies that led to the protocols. In a study by Krishnan et al from Johns Hopkins medical institute, protocol-directed weaning did not improve patient outcome, including the ICU length of stay, compared to the usual care in a closed, generously staffed medical intensive care unit [29]. When the usual care is already influenced by the available evidence and in intensive care units where there is adequate physician staffing with daily structured multi-disciplinary rounds, the benefits of the protocols may not be as pronounced as in the original studies.Our study has several limitations. Since the study was performed in a single medical center with its own unique characteristics, the findings may not be generalizable. The APACHE III database we used for the study did not include information on the rate of compliance with the protocols or evidence-based practice. We did not have the data to determine the eligibility and contraindications for each protocol. Our data also lacked the identification of the individual patients who received treatment based on the protocols. Since the four protocols were introduced at various times of the study, it is not easy to determine the effects of each protocol individually. We may not have accounted for all confounding variables although we adjusted for the severity of illness. Because of the retrospective design, our study cannot exclude the fact that unmeasured changes in patient care and unrelated to the protocols may have contributed to the improved outcome. The current study was performed over a period of 66 months. The transition period to having all the protocols available in the MICU took 24 months. Because of the long time interval it took to complete the study, we cannot avoid the potential confounding effects of frequently imperceptible changes in practice on outcome measures. Our study did not control for factors such as ICU and hospital patient volume and occupancy that may influence outcome. In the early part of our study, there were changes in the structure and staffing of the MICU. The MICU had expanded from 15 to 19 and then to 24 beds and the intensivist to bed ratio had changed from 1:15 to 1:9.5 and then to 1:15 [30]. However, we had shown these staffing and structural changes did not have significant impact on mortality in a previous publication [30]. Clinical researchers in our institution have monitored practice patterns and published studies focusing on ICU outcome in recent years. These reports may have had a Hawthorne effect. The large number of patients in our study may have led to statistically significant p values even when the clinical differences are of limited clinical value. For example, the difference in the 28-day ICU free days between the pre-protocol and protocol period was only 0.7 although the P value was < 0.05.

Conclusion

The current study suggests that the introduction of several evidence-based patient care protocols is associated with improved (small albeit significant) severity adjusted mortality in a population of critically ill adult patients admitted to a medical ICU. Using sensitivity analysis, Pronovost and colleagues have extrapolated that 167,819 lives can be saved annually by the consistent and appropriate implementation of evidence-based therapies in the intensive care unit [31]. However, previous publications have highlighted the delay and reluctance in translating research findings into practice [8-10]. Errors of omission should not be tolerated. Future studies should address the barriers to the implementation of evidence-based clinical practices in the ICU and the potential solutions to the barriers.