Service d'Anesthésie et de Réanimation, Hôpital Nord, Aix-Marseille Univ, Marseille, France.
Crit Care Med. 2012 Dec;40(12):3189-95. doi: 10.1097/CCM.0b013e31826571f2.
Clinical guidelines should provide a framework for managing patients hospitalized in intensive care units. Little is known about guideline compliance in real-life practice. To evaluate compliance rates for a large bundle of intensive care unit practice guidelines and determine factors associated with noncompliance to these guidelines.
DESIGN, SETTING, AND PATIENTS: A bundle of 13 clinical guidelines was elaborated by a group of senior physicians. Four external consultants validated the process. Then, a 1-day audit was performed at 66 participating adult intensive care units in 39 institutions by a group of 64 junior investigators supervised by senior intensivists. At the bedside, investigators collected data from 625 patients hospitalized in those units.
The eligibility and compliance rates were determined for each clinical recommendation. The rate of full compliance to each eligible clinical guideline was calculated. Mortality data were requested 28 days after the completion of the audit.
The eligibility rate ranged from 11% (sepsis bundle) to 80% (identified closest relative). The median compliance rate was 75% (60-100), ranging from 24% (sedation monitoring) to 96% (identified closest relative and bacteriological sampling before initiating antibiotics). Our results showed that only 24% (20-27) of patients in our cohort received fully compliant care. The 28-day survival probability was .77 (.73-.80).
At the bedside, clinical guidelines are fully applied in 24% of patients. Our study underlines the need to both improve the process of implementation and become cognizant of excessive proliferation of clinical guidelines.
临床指南应为重症监护病房患者的管理提供框架。关于临床实践中指南遵循情况的了解甚少。本研究旨在评估一整套重症监护实践指南的遵循率，并确定与这些指南不遵循相关的因素。
设计、地点和患者：一组资深医生制定了一套 13 项临床指南。由 4 名外部顾问对该过程进行了验证。然后，由 64 名初级研究人员在 39 家机构的 66 个参与成人重症监护病房进行了为期 1 天的审核，由资深重症监护医生监督。在床边，调查人员从这些病房中住院的 625 名患者中收集数据。
确定了每项临床建议的资格和遵循率。计算了每个符合条件的临床指南的完全遵循率。审核完成 28 天后，请求了死亡率数据。
资格率范围为 11%（脓毒症套餐）至 80%（确定最近的亲属）。中位数遵循率为 75%（60-100），范围从 24%（镇静监测）到 96%（确定最近的亲属和开始使用抗生素前进行细菌采样）。我们的研究结果表明，我们队列中只有 24%（20-27）的患者接受了完全符合要求的治疗。28 天的生存率为.77（.73-.80）。
在床边，只有 24%的患者得到了全面的临床指南应用。我们的研究强调了需要改进实施过程，并认识到临床指南的过度扩散。
