Implementation of Evidence-Based Practice
Application of evidence-based practice resulting in protocols
to standardize patient care has been shown to improve the efficiency of care and
reduce resource use.[10]
[11]
Hospitals
Figure 74-1
Graphic display of cost-effectiveness of a theoretical
treatment that adds additional cost but is effective in extending quality-adjusted
life. A quality-adjusted life-year (QALY) is a year of life gained for which the
quality of life is judged to be acceptable. The lines
represent cost per QALY. Cost per QALY depends on the patient population that receives
the intervention. For example, patients with low severity of illness receiving activated
protein C have a much higher cost per QALY than those with higher severity of illness.
must customize the protocols to fit their practice, but protocols should not be used
in place of good clinical judgment. They should be used as a complementary tool,
and the physician should be able to justify departures from the protocol. These
departures should be used to further refine the protocol so that it is not viewed
as a static entity, but rather an evolving guideline.[12]
For protocols to be effective, the hospital must be willing to invest the resources
necessary for implementation such as providing adequate staffing. For example, inadequate
nurse-to-patient ratios have been associated with a longer period of mechanical ventilation
for patients.[13]
Key personnel such as physicians,
respiratory therapists, and nursing staff should be enlisted so that the entire patient
care team helps to define the standards on which the protocol is based.
Perhaps the most difficult task in application of evidence-based
practice is determining whether a given patient with a particular clinical scenario
will benefit from that practice. Are there pathophysiologic differences in the illness
in a particular patient that may lead to a diminished treatment response? Are there
important differences in systems or provider compliance that may diminish the safety
or efficacy of the treatment? Does a patient have comorbid conditions that would
exclude her or him from a clinical trial? Despite these limitations, when applied
to large populations of patients, these practices reduce mortality and usually reduce
cost.
The following section examines the results of key studies on several
major issues in critical care. All of these recommendations are graded a
or b using the criteria listed in Table
74-3
and represent results of important clinical trials completed in the
past 5 years. Many have data supporting the use of protocol-based therapy, whereas
others are introductory management ideas that may lead to integration into future
protocols.
