Changing physicians' behavior in the intensive care unit

Improving trauma care in the ICU: best practices, quality improvement initiatives, and organization

Optimal care of critically ill trauma patients remains a challenge within modern medical systems. During the past decade, emerging technologies and organizational improvements have greatly advanced the care of these patients. The effective implementation of best practice initiatives has led to measurable improvement in outcomes while also reducing health care costs. Continued advances in the implementation of these initiatives and ICU organization are required, however, to insure that optimal care is provided to this unique patient population.

Implementing quality initiatives using a bundled approach

Critical care has been criticised for its inconsistency in implementing and evaluating evidence based practice both at national and international level. A review of the critical care literature by Berenholtz et al. (2002) identified interventions that might help prevent morbidity or mortality in the intensive care unit; from this four elements were developed into the initial ventilator care bundle. The aim of this bundle was to improve the quality of care for mechanically ventilated patients by improving compliance with relevant evidence based practice; implementation of this or an adapted cluster of interventions has been shown consistently to reduce the incidence of ventilator-associated pneumonias across countries. There are now numerous care bundles and the bundle approach to quality improvement has been proven to be effective across a number of problems, international boundaries and in a wide variety of ICU's. The bundle approach recognises that core clinical interventions, are not always consistently applied across all appropriate patients, the range of interventions within a bundle tackles the problem from a variety of different angles. Other strengths include its adaptability to the wide variety of environments and working practices of intensive care units across the world. The bundle and the method of implementation can be adapted to suit individual teams and units; however, this can also be a weakness of this approach as it limits comparability across centres. The bundle approach to quality improvement requires significant multidisciplinary engagement and resources to be effective.

Advances in the management of pneumonia in the intensive care unit: review of current thinking

Interventions to prevent pneumonia in the intensive care unit should combine multiple measures targeting the invasive devices, microorganisms and protection of the patient. Microbiological investigation is useful for evaluating the quality of the respiratory sample, and permits early modification of the regimen in light of the microbiological findings. Once pneumonia develops, the appropriateness of the initial antibiotic regimen is a vital determinant of outcome. Three questions should be formulated: (1) is the patient at risk of acquiring methicillin-resistant Staphylococcus aureus, (2) is Acinetobacter baumannii a problem in the institution, and (3) is the patient at risk of acquiring Pseudomonas aeruginosa? Antibiotic therapy should be started immediately and must circumvent any pathogen resistance mechanisms developed after previous antibiotic exposure. Therefore, antibiotic choice should be institution-specific and patient-oriented.

Pneumonia in the intensive care unit

OBJECTIVE

To update the state-of-the-art on pneumonia in adult patients in the intensive care unit (ICU), with special emphasis on new developments in management.

METHODS

We searched MEDLINE, using the following keywords: hospital-acquired pneumonia, ventilator-associated pneumonia and healthcare-associated pneumonia, diagnosis, therapy, prevention.

RESULTS

Interventions to prevent pneumonia in the ICU should combine multiple measures targeting the invasive devices, microorganisms, and protection of the patient. Once pneumonia develops, the appropriateness of the initial antibiotic regimen is a vital determinant of outcome. Three questions should be formulated: a) Is the patient at risk of methicillin-resistant Staphylococcus aureus?; b) Is Acinetobacter baumannii a problem in the institution?; and c) is the patient at risk of Pseudomonas aeruginosa? Antibiotic therapy should be started immediately and must circumvent pathogen-resistance mechanisms developed after previous antibiotic exposure. Therefore, antibiotic choice should be institution specific and patient oriented. Microbiologic investigation is useful on evaluating the quality of the respiratory sample and permits early modification of the regimen in light of the microbiologic findings.

CONCLUSION

A decision tree outlining an approach to the evaluation and management of ventilator-associated pneumonia is provided.