急性呼吸窘迫综合征管理中的实践差异：使用基于网络的教学工具将证据和临床医生教育带到床边。

Practice variability in management of acute respiratory distress syndrome: bringing evidence and clinician education to the bedside using a web-based teaching tool.

作者信息

Belda Thomas E, Gajic Ognjen, Rabatin Jeffrey T, Harrison Barry A

机构信息

Department of Anesthesiology, Mayo Clinic, 200 First Street SW, 2-114 Old Marian Hall, Rochester MN 55905, USA.

出版信息

Respir Care. 2004 Sep;49(9):1015-21.

PMID:15329172

Abstract

BACKGROUND

Clinical practice often lags behind publication of evidence-based research and national consensus guidelines.

OBJECTIVE

To assess practice variability in the clinical management of acute respiratory distress syndrome (ARDS) and test an evidence-based, online clinician-education tool designed to improve intensive-care clinicians' understanding of current evidence about ARDS management.

METHODS

We surveyed 117 intensive care clinicians (16 critical care physician specialists, 28 resident physicians, 50 critical care nurses, and 23 respiratory therapists) with an online questionnaire in our tertiary academic institution. Fifty of the original respondents (12 residents, 26 critical care nurses, and 12 respiratory therapists) also responded to a repeat survey that included context-sensitive hypertext links to a summary of critically appraised primary articles regarding ARDS management, to determine if the responses changed after the clinicians had read the evidence-based summary information.

RESULTS

Critical care physician specialists were most likely to choose the low-tidal-volume (low-VT) ventilation strategy and protocol-based ventilator weaning and were least likely to choose neuromuscular blockade or parenteral nutrition (p < 0.05). In a paired comparison, individual respondents were more likely to choose treatment options that are based on stronger evidence (low-VT, daily interruption in sedation, and protocol weaning [p < 0.01]). We also reviewed the medical records of 100 patients who were mechanically ventilated for > 48 h, during the 6 months before and after the survey, from which we identified 45 ARDS patients. Following the clinician-education intervention, ARDS patients were less likely to receive potentially injurious high-VT ventilation (mean day-3 VT 10.3 +/- 2.3 mL/kg before vs 8.9 +/- 1.7 mL/kg after, p = 0.02).

CONCLUSION

Web-based teaching tools are useful to educate intensive-care practitioners and to promote evidence-based practice.

摘要

背景

临床实践往往落后于循证研究成果的发表以及国家共识指南。

目的

评估急性呼吸窘迫综合征（ARDS）临床管理中的实践差异，并测试一种循证的在线临床医生教育工具，该工具旨在提高重症监护临床医生对当前ARDS管理证据的理解。

方法

我们在一所三级学术机构中通过在线问卷对117名重症监护临床医生（16名重症医学专科医生、28名住院医师、50名重症监护护士和23名呼吸治疗师）进行了调查。50名最初的受访者（12名住院医师、26名重症监护护士和12名呼吸治疗师）还对一项重复调查做出了回应，该调查包含与关于ARDS管理的经严格评估的原始文章摘要的上下文敏感超文本链接，以确定临床医生阅读循证摘要信息后其回答是否发生变化。

结果

重症医学专科医生最有可能选择低潮气量（低VT）通气策略和基于方案的呼吸机撤机，最不可能选择神经肌肉阻滞剂或肠外营养（p < 0.05）。在配对比较中，个体受访者更有可能选择基于更强证据的治疗方案（低VT、每日中断镇静和方案撤机 [p < 0.01]）。我们还回顾了调查前后6个月内100名机械通气超过48小时患者的病历，从中确定了45例ARDS患者。在临床医生教育干预后，ARDS患者接受可能有害的高VT通气的可能性降低（第3天平均VT之前为10.3 +/- 2.3 mL/kg，之后为8.9 +/- 1.7 mL/kg，p = 0.02）。