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What Differs from Theory to Practice?
Emel EryükselMarmara University, Pulmonary and
Critical Care
Intrathoracic Pressures and Breathing
Ventilation Strategies
• Improved safety
• Improved patient comfort
• Rapid response to change in patient condition
Ventilation Strategies
• Improved safety
• Improved patient comfort
• Rapid response to change in patient condition
Lung Injury Caused by Forcesat Low and High Lung Volumes
n engl j med 369;22
adherence to lung protective ventilation?
• -Of the 485 patients, 417 (86%) received 50% or less and 68 (14%)
received more than 50% of their twice daily ventilator settings adherent to
lung protective ventilation. A total of 180 (37%) patients never received
lung protective ventilation during any of their twice daily ventilator
settings.-
WHY?
What causes physicians to change the way they practice?
Changes in practice are sometimes rapid and dramatic.
laparoscopic cholecystectomy …..
education
• Why are most physicians not influenced by practice guidelines?
scientific knowledge to specific patients
SUMMARIZE THE EVIDENCE
• To change practice, the evidence must be summarized concisely into several key interventions….
• For ALI, the evidence supports LPV, which can be defined as providing a tidal volume less than or equal to 6 ml/kg of predicted body weight and a plateau pressure of less than or equal to 30 cm H2O….
IDENTIFY LOCAL BARRIERS TO PRACTICE COMPLIANCE
diagnostic uncertainty
Severity
Patient’s Weight..
• 50+ 0.91(centimeters of height-152.4) male
• 45.5+0.91(centimeters of height-152.4) female
ICU TEAM
• Overall, organizational barriers and perceived barriers related to clinician attitudes and behaviors were lower among physicians compared with nurses and respiratory therapists.
• Physicians specializing in internal medicine (including pulmonary/critical care) perceived lower barriers and scored higher on the Knowledge Test compared with surgery
• Barriers were lower and Knowledge Test scores higher among fellows and attending physicians vs. interns and residents, who have much less experience working in the ICU.
MEASURE PERFORMANCE
• Clinicians can measure performance using processes of care (e.g., LPV use), outcomes of care (in-hospital mortality)or both.
ENSURE THAT ALL PATIENTS RECEIVE THE THERAPY
Educating clinicians
• that they are aware of the evidence, agree with it, and understand the actions needed to comply with the evidence.
Executing
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