chapter  23
16 Pages

Crossing the Quality Chasm in Critical Care: Changing Ventilator Management in Patients with ALI

WithMargaret J. Neff, Gordon D. Rubenfeld

For years the concept of ‘‘evidence-based critical care’’ was largely theore-

tical because of a lack of high-grade clinical trial evidence demonstrating a survival benefit for any specific therapy for acute lung injury (ALI) and

severe sepsis. The last decade has produced a number of clinical trials in

critical care demonstrating significant effects on important clinical out-

comes (lung-protective ventilation for ALI, activated protein C for severe

sepsis, and protocolized ventilator weaning) and other trials raising ques-

tions about the benefit of treatments thought to be effective (human growth

hormone for chronic critical illness, pulmonary artery catheterization, and

colloid resuscitation). A natural assumption would be that this evidence would be followed by the rapid integration of these results into clinical prac-

tice. Experience tells us otherwise. Whether trying to change practice in

business or medicine, change is a slow process. Entire industries are devel-

oped to improve systems and processes to incorporate change into the

industry. Critical care medicine is new to this phenomenon and also to

the situation of having evidence-based medicine with which to guide clinical

practice. Until recently, the problem was not knowing the answer; now the problem is figuring out how to apply the answers.