In my introductory talk I drew attention to two areas that I believe to be of key importance in intensive care medicine today. First, the ‘protocol’ issue: Protocols, defined as the outline or plan for a treatment programme, have received some hard sell in recent years, in many fields of medicine, and intensive care medicine is no exception. Well-designed protocols can certainly simplify patient management and care, but do they improve it? One of the major problems with protocols in the ICU environment is that there is still so much we do not know and therefore protocols are often drawn up from guidelines and recommendations that themselves are based on relatively little high grade evidence. Randomised controlled trials are notoriously difficult to conduct and interpret in the ICU population, so much of our evidence for or against interventions must be based on alternative study design, case series, or expert opinion (Vincent JL. Evidence-based medicine in the ICU: important advances and limitations. Chest 2004; 126: 592-600). In addition, once a protocol is established, does it mean that is the end of the story for that disease process, or for that group of patients? The fact that a protocol has been developed should not discourage us from conducting further research in that field. Protocols must not be considered as permanent; the protocol user must still be encouraged to rationalise the care they are giving, and protocols must be adapted as new evidence becomes available. Another problem with protocols is that many ICU patients do not fit neatly into one diagnostic category, but have many processes present at the same time, and it may be difficult to determine which protocol, if any, should be applied.
While I believe treatment protocols can be useful in certain circumstances, I believe checklists have a much wider application and are much more valuable to ensure that each patient receives the necessary care, without the limitations of the stricter protocol approach. We recently developed the FastHug (Feeding, Analgesia/Sedation, Thrombosis prophylaxis, head of the bed elevated, ulcer prophylaxis, glucose levels) mnemonic Vincent JL. Give your patient a fast hug (at least) once a day (Crit Care Med 2005; 33: 1225-9), a ‘mental’ checklist of the essential aspects of care for all critically ill patients).
This leads nicely to my second key point, and that is the importance of good ICU teamwork. There is no doubt that an ICU managed by a trained intensivist improves patient outcomes. But the intensivist can achieve little without the support of the full ICU team, which includes nurses, physiotherapists, pharmacists, laboratory and equipment technicians, amongst others.
Various members of the team will see patients at different times during the day and in different circumstances. Each team member can apply the FastHug every time they see a patient to ensure that the basic essentials of care are being achieved. For example, a nurse may realise that a patient is not receiving thrombo-embolism prophylaxis and can then propose that it be prescribed, or a physiotherapist may suspect a patient is overly sedated and suggest sedative doses be adjusted. This system thus encourages active participation of all staff members in patient treatment. Around then, the ICU becomes a time when all the ICU team members can join together at the bedside and contribute to a patient’s ongoing care. Indeed bedside rounds improve staff communication and may result in better outcomes (Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E. Organisational characteristics of intensive care units related to outcomes of abdominal aortic surgery.
J A M A 1999; 281: 1310-7). Only when we work together, with the patient at the centre of our preoccupations, can we expect to achieve the best outcomes for our patients.