Prospective Assessment of the Feasibility of a Trial of Low-Tidal Volume Ventilation for Patients with Acute Respiratory Failure.

Rationale: Low-tidal volume ventilation (LTVV; 6 ml/kg) benefits patients with acute respiratory distress syndrome and may aid those with other causes of respiratory failure. Current early ventilation practices are poorly defined.

Objectives: We observed patients with acute respiratory failure to assess the feasibility of a pragmatic trial of LTVV and to guide experimental design.

Automated detection of physiologic deterioration in hospitalized patients.

Objective: Develop and evaluate an automated case detection and response triggering system to monitor patients every 5 min and identify early signs of physiologic deterioration.

Materials And Methods: A 2-year prospective, observational study at a large level 1 trauma center. All patients admitted to a 33-bed medical and oncology floor (A) and a 33-bed non-intensive care unit (ICU) surgical trauma floor (B) were monitored.

Multicenter implementation of a severe sepsis and septic shock treatment bundle.

Rationale: Severe sepsis and septic shock are leading causes of intensive care unit (ICU) admission, morbidity, and mortality. The effect of compliance with sepsis management guidelines on outcomes is unclear.

Objectives: To assess the effect on mortality of compliance with a severe sepsis and septic shock management bundle.

The evolution of eProtocols that enable reproducible clinical research and care methods.

Unnecessary variation in clinical care and clinical research reduces our ability to determine what healthcare interventions are effective. Reducing this unnecessary variation could lead to further healthcare quality improvement and more effective clinical research. We have developed and used electronic decision support tools (eProtocols) to reduce unnecessary variation.

Culture of early mobility in mechanically ventilated patients.

Physical deconditioning and prolonged motor weakness accompanying critical illness have profound and lasting consequences for both patients and their informal caregivers. The etiology is multifactorial and the effects may be mitigated by an early mobility process. Early mobility is facilitated by change in intensive care unit culture that requires clinicians to: 1) reorganize and manage current practices that have the potential to interfere with mobility; 2) create a strategy to improve the level of teamwork; and 3) link effective practice intervention and teamwork with short- and long-term patient-centered outcomes.

An electronic protocol for translation of research results to clinical practice: a preliminary report.

Introduction: We evaluated the feasibility of using an electronic protocol developed for research use (Research-eProtocol-insulin) for blood glucose management in usual intensive care unit clinical practice.

Methods: We implemented the rules of Research-eProtocol-insulin in the electronic medical record of the Intermountain Healthcare hospital system (Clinical-eProtocol-insulin) for use in usual clinical practice. We evaluated the performance of Clinical-eProtocol-insulin rules in the intensive care units of seven Intermountain Healthcare hospitals and compared this performance with the performance of Research-eProtocol-insulin at the LDS Hospital Shock/Trauma/Respiratory Intensive Care Unit.

Assessing data quality in manual entry of ventilator settings.

Objective: To evaluate the data quality of ventilator settings recorded by respiratory therapists using a computer charting application and assess the impact of incorrect data on computerized ventilator management protocols. DESIGN An analysis of 29,054 charting events gathered over 12 months from 678 ventilated patients (1,736 ventilator days) in four intensive care units at a tertiary care hospital.

Measurements: Ten ventilator settings were examined, including fraction of inspired oxygen (Fio (2)), positive end-expiratory pressure (PEEP), tidal volume, respiratory rate, peak inspiratory flow, and pressure support.

Monitoring outcomes with relational databases: does it improve quality of care?

There are 3 key ingredients in improving quality of medial care: 1) using a scientific process of improvement, 2) executing the process at the lowest possible level in the organization, and 3) measuring the results of any change reliably. Relational databases when used within these guidelines are of great value in these efforts if they contain reliable information that is pertinent to the project and used in a scientific process of quality improvement by a front line team. Unfortunately, the data are frequently unreliable and/or not pertinent to the local process and is used by persons at very high levels in the organization without a scientific process and without reliable measurement of the outcome.

Computers in the ICU: where we started and where we are now.

The first use of computers in critical care units were described in the mid 1960s. They reported the use of very large mainframe computers that filled entire rooms yet had very limited memory and processing capacities by today's standards. These were limited to only a few institutions until microprocessors were developed increasing computation speed and expanding memory capacity by many magnitudes.

Guidelines for critical care medicine training and continuing medical education.

Objective: Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care.

Participants: A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine.

Effects of recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome ventilated with high positive end-expiratory pressure.

Objective: Positive end-expiratory pressure (PEEP) and recruitment maneuvers (RMs) may partially reverse atelectasis and reduce ventilation-associated lung injury. The purposes of this study were to assess a) magnitude and duration of RM effects on arterial oxygenation and on requirements for oxygenation support (Fio2/PEEP) in patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS) receiving ventilation with low tidal volumes and high levels of PEEP; and b) frequency of adverse respiratory and circulatory events attributable to RMs.

Design: Prospective, randomized, crossover study.

The effect of computer-generated reminders on charting deficiencies in the ICU.

Objective: To examine the effect of computer-generated reminders on nurse charting deficiencies in two intensive care units.

Design: Nurses caring for a group of 60 study patients received patient-specific paper reminder reports when charting deficiencies were found at mid-day. Nurses caring for a group of 60 control patients received no reminders.

Implementation of an electronic logbook for intensive care units.

Logbooks of patients treated in acute care units are commonly maintained; the data may be used to justify resource use, analyze patient outcomes, and encourage clinical research. We report herein the conversion of a paper-based logbook to an electronic logbook in three hospital intensive care units. The major difference between the paper logbook and electronic logbook data was the addition of clinician-entered data to the electronic logbook.

Hyperbaric oxygen for acute carbon monoxide poisoning.

Background: Patients with acute carbon monoxide poisoning commonly have cognitive sequelae. We conducted a double-blind, randomized trial to evaluate the effect of hyperbaric-oxygen treatment on such cognitive sequelae.

Methods: We randomly assigned patients with symptomatic acute carbon monoxide poisoning in equal proportions to three chamber sessions within a 24-hour period, consisting of either three hyperbaric-oxygen treatments or one normobaric-oxygen treatment plus two sessions of exposure to normobaric room air.

The vortex: families' experiences with death in the intensive care unit.

Background: Lack of communication from healthcare providers contributes to the anxiety and distress reported by patients' families after a patient's death in the intensive care unit.

Objective: To obtain a detailed picture of the experiences offamily members during the hospitalization and death of a loved one in the intensive care unit.

Methods: A qualitative study with 4 focus groups was used.

Intensive care nurses' experiences with end-of-life care.

Background: With much attention being focused on how patients die and whether or not they are provided appropriate care, the care of dying patients in intensive care units must be described and improved.

Objectives: To describe end-of-life care in intensive care units as perceived by critical care nurses who have taken care of dying patients.

Methods: A semistructured interview guide was developed and revised after pretesting in a focus group of faculty clinicians with extensive, recent experience in intensive care.

Results of a collaborative quality improvement program on outcomes and costs in a tertiary critical care unit.

Objective: To demonstrate that by using the knowledge and skills of the primary care provider and by applying statistical and scientific principles of quality improvement, outcomes can be improved and costs significantly reduced.

Design: A before and after quasi-experimentally designed trial using historical controls plus an analysis of costs in areas not influenced by intensive care unit (ICU) practice to control for possible secular changes.

Setting: A tertiary ICU.

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma.

Objective: To compare the effectiveness of calf-thigh sequential pneumatic compression devices with the effectiveness of plantar venous intermittent pneumatic compression devices in prevention of venous thrombosis after major trauma.

Subjects And Methods: We evaluated 181 consecutive patients after major trauma without lower extremity injuries that precluded the use of pneumatic compression devices. We randomly assigned 149 patients to either calf-thigh sequential pneumatic compression or plantar venous pneumatic compression.