Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California Davis Medical Center, Sacramento, CA.
Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD.
Crit Care Med. 2020 Dec;48(12):1845-1847. doi: 10.1097/CCM.0000000000004373.
Tools for standardizing patient care can take many forms, including but not limited to, bundles, quality improvement and performance measures, guidelines, and protocols. Each is intended to improve compliance with interventions believed to be supported by the best available evidence, ensuring consistency of management across all patients with the ultimate goal of improving outcomes. However, in the ICU, patients typically present with complex acute illnesses and accompanying comorbidities, requiring careful tailoring of interventions and treatments for each individual patient. The rapidly changing nature of the underlying conditions also demands continuous reassessment and modification of each patient’s management on a frequent and sometimes moment-by-moment basis. Disrupting this individualized treatment approach by imposing prescriptive, overly restrictive, “one-size-fits-all” standardized treatments in the critical care setting may prevent the clinician from meeting individual patients’ needs and decrease care quality (1). This problem is compounded if the standardization tools adopted are not only inflexible but also have a poorly supported or entirely absent scientific basis. Importantly, identifiable patient subcategories often exist that fit poorly into the populations for which many interventions were developed and tested. Of equal concern, critical care trainees may become dependent on a standardized/cookbook approach to care and fail to recognize and learn how treatments must be tailored for the unique needs of each critically ill patient. Rather than rigidly standardizing critical care, approaches that recognize this complexity and are both scientifically sound and responsive to patient differences should be readily available to critical care clinicians without replacing sensible clinical judgment. Such strategies that acknowledge the limitations of available evidence hold more hope of improving, rather than inadvertently worsening, the outcome.
用于规范患者护理的工具可以采用多种形式，包括但不限于：捆绑式、质量改进和绩效措施、指南和方案。每种方法都旨在提高对基于最佳现有证据的干预措施的依从性，确保对所有患者的管理保持一致，最终目标是改善结果。然而，在 ICU 中，患者通常患有复杂的急性疾病和伴随的合并症，需要为每个患者精心调整干预措施和治疗方法。基础疾病的快速变化性质也要求频繁且有时需要实时重新评估和修改每位患者的管理。在重症监护环境中通过强制实施规定性、过度限制、“一刀切”的标准化治疗来破坏这种个体化治疗方法，可能会导致临床医生无法满足个别患者的需求并降低护理质量 (1)。如果采用的标准化工具不仅缺乏灵活性，而且缺乏或完全缺乏科学依据，那么这个问题就会更加严重。重要的是，通常存在明显的患者亚类，这些患者与许多干预措施开发和测试所针对的人群不太匹配。同样令人担忧的是，重症监护培训生可能会依赖标准化/食谱式的护理方法，而无法识别并了解如何根据每个重症患者的独特需求调整治疗方法。与其僵化地标准化重症监护，不如采用既能科学合理又能应对患者差异的方法，为重症监护临床医生提供支持，而不是替代合理的临床判断。这种承认现有证据局限性的策略更有希望改善结果，而不是无意中使结果恶化。
