Treatment Algorithms in Critical Care: Do They Improve Outcomes?

2010 ◽  
Vol 23 (1) ◽  
pp. 61-68 ◽  
Author(s):  
Stephen W. Nissen ◽  
Keith M. Olsen
Keyword(s):  
Critical Care ◽  
Treatment Guidelines ◽  
Medical Center ◽  
Treatment Guideline ◽  
Treatment Protocol ◽  
Clinical Trial Data ◽  
Critically Ill Patient ◽  
Successful Implementation ◽  
Treatment Protocols ◽  
Order Form

Patients admitted to the intensive care unit (ICU) often have significant underlying morbidities that require complex treatment plans. Because of these complexities, numerous guidelines have been developed to facilitate the management of the critically ill patient. Some of these guidelines include sepsis, community-acquired and ventilator-associated pneumonia, sedation, and glycemic control. Once guidelines are written, a treatment protocol must be developed and implemented within the critical care unit. Our medical center has implemented multiple treatment protocols, often with preprinted order sets with various degrees of success. In 2003, we implemented and later evaluated a sedation order form and protocol. Patients whose sedation was initiated with a standardized order form had more frequent sedation score assessment, less time between sedation vacations, reduced ICU length of ICU stay, and a trend in reduction of ventilator days. However, only 37% of eligible patients were treated using the order form and the protocol, despite the potentially beneficial effects. Some recommendations within guidelines are based on sound clinical evidence supported by randomized controlled trials, although others are based on expert opinion only. The most often-cited reason for protocol noncompliance is disagreement with the published clinical trial data. This paper examines both infectious and noninfectious treatment guidelines and the supportive evidence that they improved patient outcomes. In addition, strategies for successful implementation of a treatment guideline are discussed for clinicians to follow in order to maximize clinical outcomes.

scholarly journals Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments

CJEM ◽  
2015 ◽  
Vol 17 (6) ◽  
pp. 656-661 ◽  
Author(s):  
Steven A Skitch ◽  
Rahim Valani
Keyword(s):  
Diabetic Ketoacidosis ◽  
Cerebral Edema ◽  
Treatment Guidelines ◽  
Treatment Protocol ◽  
Serum Glucose ◽  
National Guidelines ◽  
Fluid Bolus ◽  
Treatment Protocols ◽  
Maintenance Fluid ◽  
Potassium Replacement

ABSTRACTObjectiveDiabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences.MethodsPediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema.ResultsResponses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5–20 mL/kg) and length of time boluses should be administered (20–120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration.ConclusionsThis is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

Computer Implementation of the Hierarchical-Modular Approach to Treatment Protocols

1982 ◽  
Vol 21 (03) ◽  
pp. 117-126 ◽  
Author(s):  
S. Michelson ◽  
M. Ben-Bassat ◽  
A. Macneil ◽  
M. H. Weil
Keyword(s):  
Critical Care ◽  
Knowledge Base ◽  
Life Support ◽  
Treatment Protocol ◽  
Modular Approach ◽  
Computer Implementation ◽  
Treatment Protocols ◽  
Treatment Information ◽  
Simple Language ◽  
Medical Disciplines

A computer implementation of the hierarchical modular approach to treatment protocols [1] is presented. By this approach the clinical treatment is defined in terms of a hierarchical structure composed of several substructures each varying with the complexity of treatment-related action that is required.The treatment protocol software consists of two major components. The first elicits treatment protocols from experts and stores them in the system’s knowledge base. The second component accesses those elements of the knowledge base relevant to the disorders and specific features (medical findings) of the patient, and drives the display of treatment information tailored specifically to the particular patient. The system interacts with the user in a friendly and very simple language. Displays are formatted in a structured manner and contain as much or as little detail as necessary. This system may find application in various areas, including generation of nursing and life support protocols as well as treatment protocols for critical care and other medical disciplines.

Treatment Outcome after Two-Stage Palatal Closure in Unilateral Cleft Lip and Palate: A Comparison with Eurocleft

2005 ◽  
Vol 42 (5) ◽  
pp. 512-516 ◽  
Author(s):  
Pieter J. P. M. Nollet ◽  
Christos Katsaros ◽  
Martin A. van't Hof ◽  
Gunvor Semb ◽  
William C. Shaw ◽  
...  
Keyword(s):  
Treatment Outcome ◽  
Repeated Measures ◽  
Cleft Lip ◽  
Cleft Lip And Palate ◽  
Medical Center ◽  
Treatment Protocol ◽  
Dental Arch ◽  
Treatment Results ◽  
Two Stage ◽  
Treatment Protocols

Objective To evaluate dental arch relationships of patients with unilateral cleft lip and palate (UCLP) treated with a two-stage palatal closure and to compare them with the six centers from the Eurocleft study that used various treatment protocols. Design Repeated-measures study. Setting Cleft Palate Craniofacial Unit of Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands. Patients Records of 9-year-old children with complete unilateral cleft lip and palate (n = 43) were included. Interventions The dental arch relationships of these patients were assessed by applying the Goslon Yardstick and subsequently compared with the Goslon outcome of the six-center Eurocleft study. Mean Outcome Measures Statistics of intra- and interexaminer agreement. Results For the Nijmegen UCLP group, 9% of dental arch relationships had a Goslon score of 1, 52% had a score of 2, 30% has a score of 3, 9% had a score of 4, and none had a score of 5. The mean Nijmegen Goslon score showed no significant differences with Eurocleft centers A, B, and E, which achieved the best treatment results, but did significantly differ from Goslon outcomes of Eurocleft centers D (p < .001), C, and F (p < .01), which had relatively poor treatment outcome. Conclusions Treatment outcome of the patients in the Nijmegen UCLP group treated with two-stage palatal closure was comparable with the results of the Eurocleft centers with the best outcome. Treatment protocol could not explain differences in the quality of treatment results.

The Role of Physical Exercise in Obesity and Diabetes

2018 ◽  
Vol 66 (3) ◽  
Keyword(s):  
Type 2 Diabetes ◽  
Type 1 Diabetes ◽  
Glycemic Control ◽  
Physical Exercise ◽  
Treatment Guidelines ◽  
Treatment Guideline ◽  
Obesity And Diabetes ◽  
Regular Physical Exercise

The prevalence of obesity is increasing world-wide. Obesity is associated with a plethora of metabolic and clinical constraints, which result in a higher risk for the development of cardiovascular complications and metabolic disease, particularly insulin resistance and type 2 diabetes. Obesity is an acknowledged determinant of glycemic control in patients with type 1 diabetes and accounts for the majority of premature death due to cardiovascular events. Physical exercise is generally recommended in patients with diabetes in order to prevent the development of or reduce existing obesity, as adopted by every international treatment guideline so far. Regular physical exercise has a beneficial impact on body composition, cardiovascular integrity, insulin sensitivity and quality of life. However, only a minority of patients participates in regular physical exercise, due to individual or ­disease-related barriers. In type 2 diabetes, there is robust evidence for beneficial effects of physical exercise on glycemic control, cardiovascular health and the development of diabetes-related long-term complications. In type 1 diabetes and patients treated with insulin, a higher risk for exercise-­related hypoglycemia has to be considered, which requires certain prerequisites and adequate adaptions of insulin ­dosing. Current treatment guidelines do only incompletely address the development of exercise-related hypoglycemia. However, every patient with diabetes should participate in regular physical exercise in order to support and enable ­sufficient treatment and optimal glycemic control.

Protocols in Heart and Lung Transplantation: An Essential Guide to Preoperative Assessment and Timing to Improve Outcomes

2004 ◽  
Vol 3 (1) ◽  
pp. 20-25
Author(s):  
Victor Tapson ◽  
Robert Frantz ◽  
John Conte
Keyword(s):  
North Carolina ◽  
Pulmonary Hypertension ◽  
Critical Care ◽  
Lung Transplantation ◽  
Medical Center ◽  
Preoperative Assessment ◽  
Assistant Professor ◽  
Associate Professor ◽  
Johns Hopkins University ◽  
Duke University

This discussion was moderated by Victor Tapson, MD, Editor-in-Chief of Advances in Pulmonary Hypertension and Associate Professor, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. The participants included Robert Frantz, MD, Assistant Professor of Medicine, Cardiovascular Division, Mayo Clinic, Rochester, Minnesota; and John Conte, MD, Associate Professor of Surgery and Director of Heart and Lung Transplantation, Johns Hopkins University, Baltimore, MD.

scholarly journals Impact of Critical Care Consultation Requests for Avoidable Central Venous Catheters on Medical-Surgical Units

2020 ◽  
Vol 41 (S1) ◽  
pp. s258-s258
Author(s):  
Madhuri Tirumandas ◽  
Theresa Madaline ◽  
Gregory David Weston ◽  
Ruchika Jain ◽  
Jamie Figueredo
Keyword(s):  
Critical Care ◽  
High Risk ◽  
Medical Center ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Bloodstream Infections ◽  
Central Line ◽  
Central Venous Catheters ◽  
High Risk Population ◽  
Central Venous

Background: Although central-line–associated bloodstream infections (CLABSI) in US hospitals have improved in the last decade, ~30,100 CLABSIs occur annually.1,2 Central venous catheters (CVC) carry a high risk of infections and should be limited to appropriate clinical indications.6,7 Montefiore Medical Center, a large, urban, academic medical center in the Bronx, serves a high-risk population with multiple comobidities.8–11 Despite this, the critical care medicine (CCM) team is often consulted to place a CVC when a peripheral intravenous line (PIV) cannot be obtained by nurses or primary providers. We evaluated the volume of CCM consultation requests for avoidable CVCs and related CLABSIs. Methods: Retrospective chart review was performed for patients with CCM consultation requests for CVC placement between July and October 2019. The indication for CVC, type of catheter inserted or recommended, and NHSN data were used to identify CLABSIs. CVCs were considered avoidable if a PIV was used for the stated indication and duration of therapy, with no anatomical contraindications to PIV in nonemergencies, according to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).6Results: Of 229 total CCM consults, 4 (18%) requests were for CVC placement; 21 consultations (9%) were requested for avoidable CVCs. Of 40 CVC requests, 18 (45%) resulted in CVC placement by the CCM team, 4 (10%) were deferred for nonurgent PICC by interventional radiology, and 18 (45%) were deferred in favor of PIV or no IV. Indications for CVC insertion included emergent chemotherapy (n = 8, 44%) and dialysis (n = 3, 16%), vasopressors (n = 3, 16%), antibiotics (n = 2, 11%) and blood transfusion (n = 2, 11%). Of 18 CVCs, 9 (50%) were potentially avoidable: 2 short-term antibiotics and rest for nonemergent indications; 2 blood transfusions, 1 dialysis, 2 chemotherapy and 2 vasopressors. Between July and October 2019, 6 CLABSIs occurred in CVCs placed by the CCM team; in 3 of 6 CLABSI events (50%), the CVC was avoidable. Conclusions: More than half of consultation requests to the CCM team for CVCs are avoidable, and they disproportionately contribute to CLABSI events. Alternatives for intravenous access could potentially avoid 9% of CCM consultations and 50% of CLABSIs in CCM-inserted CVCs on medical-surgical wards.Funding: NoneDisclosures: None

scholarly journals Policies and procedures governing patient portal use at an Academic Medical Center

JAMIA Open ◽  
2019 ◽  
Vol 2 (4) ◽  
pp. 479-488
Author(s):  
Bryan D Steitz ◽  
Joseph Isaac S Wong ◽  
Jared G Cobb ◽  
Brian Carlson ◽  
Gaye Smith ◽  
...  
Keyword(s):  
Government Regulation ◽  
Medical Center ◽  
Academic Medical Center ◽  
Successful Implementation ◽  
Patient Portal ◽  
Patient Portals ◽  
Identity Verification ◽  
Policies And Procedures ◽  
Academic Medical ◽  
And Function

Abstract Background and Objective Patient portal use has increased over the last two decades in response to consumer demand and government regulation. Despite growing adoption, few guidelines exist to direct successful implementation and governance. We describe the policies and procedures that have governed over a decade of continuous My Health at Vanderbilt (MHAV) patient portal use. Methods We examined MHAV usage data between May 2007 and November 2017. We classified patient portal activity into eight functional categories: Appointment, Billing, Document Access, Genetics, Health Result, Immunization, Medication, and Messaging. We describe our operating policies and measure portal uptake, patient account activity, and function use over time. Results By the end of the study period, there were 375 517 registered accounts. Policies made MHAV available to competent adults and adolescents 13 and over. Patients signed up for a limited access account online, which could be upgraded to a full-access account after identity verification. Patients could assign proxy accounts to family and caregivers, which permitted nonpatient access to select MHAV functions. Laboratory and radiology results were accessible via MHAV. Results were classified into three groups based on sensitivity, which govern the length of delay before results appeared in MHAV. Discussion and Conclusion Patient portals offer significant opportunity to engage patients in their healthcare. However, there remains a need to understand how policies can promote uptake and use. We anticipate that other institutions can apply concepts from our policies to support meaningful patient portal engagement.

Compassion Fatigue and the Healthy Work Environment

2017 ◽  
Vol 28 (4) ◽  
pp. 351-358 ◽  
Author(s):  
Lesly Kelly ◽  
Michael Todd
Keyword(s):  
Critical Care ◽  
Work Environment ◽  
Compassion Fatigue ◽  
American Association ◽  
Medical Center ◽  
Academic Medical Center ◽  
Compassion Satisfaction ◽  
Critical Care Nurses ◽  
Healthy Work Environment ◽  
Healthy Work

Background:Burnout is a concern for critical care nurses in high-intensity environments. Studies have highlighted the importance of a healthy work environment in promoting optimal nurse and patient outcomes, but research examining the relationship between a healthy work environment and burnout is limited.Objective:To examine how healthy work environment components relate to compassion fatigue (eg, burnout, secondary trauma) and compassion satisfaction.Methods:Nurses (n = 105) in 3 intensive care units at an academic medical center completed a survey including the Professional Quality of Life and the American Association of Critical-Care Nurses’ Healthy Work Environment standards.Results:Regression models using each Healthy Work Environment component to predict each outcome, adjusting for background variables, showed that the 5 Healthy Work Environment components predicted burnout and that meaningful recognition and authentic leadership predicted compassion satisfaction.Conclusions:Findings on associations between healthy work environment standards and burnout suggest the potential importance of implementing the American Association of Critical-Care Nurses’ Healthy Work Environment standards as a mechanism for decreasing burnout.

Sign in / Sign up

Export Citation Format

Share Document