Kritikus programs improve outcomes through education and systems changes to assist clinicians in prompt recognition and mobilization of best practice resources for at-risk patients.
Utilizing a back-to-basics approach patients outcomes are often improve by “bread and butter” care rather than “razzle-dazzle” interventions. In early clinical decline recognizing the implications of increased respiratory rate, prolonged capillary refill and/or altered mental status can have more impact with less cost on promting early diagnosis and interventions than more involved diagnostics. The programs highlighted below have been effective in improving care while keeping the approach simple.
SHOCK
Unreversed Shock is 100% fatal. if not recognized in its earliest stages it often leads to multi-organ failure and long hospital stays. Utilizing a four-arm system of care foced on the afferent arm for recognition and treatment of shock patients can further improve outcomes
Vital Signs & 10 Signs of Vitality
Determining vital signs correctly is the first hurdle in prompt recognition of at-risk patients. Respiratory rate is often inaccurately reported, yet one of the most important parameters of early critical illness. Measuring vital signs correctly, and expanding them with additional easy to measure bedside (i.e. capillary refill) metrics can improve sensitivity and specificity in detection of at-risk patients.
Rapid Response Systems
Conventional RRS frequently focuses on the efferent arm or response team. This does little to improve event detection. Redesigning a RRS to be a complete four-arm system focused on the afferent arm or beside nurse will improve early event detection and patient outcomes.
SEPSIS
Sepsis is responsible for about a one third of RRT alerts (approximately 1/3 respirator insufficiency, 1/3 hypovolemia and SIRS) and significant morbidity and mortality. Early recognition of subtle physiologic abnormalities and prompt basic treatment can dramatically improve outcomes. In septic shock, early support of the respiratory system with noninvasive or invasive ventilation allows blood to be redirected to the abdomen from diaphragms and intercostal muscles, reducing organ ischemic.
Cardiac Arrest
Progress in CPR techniques have had limited impact on improving good neurological outcomes and survival. Newer techniques including end tidal CO2 and continuous real time automated feedback on depth, rate and recoil of compressions offer promise as a resuscitation guide.
Positional Therapy for ARDS
In ARDS, Ventilator Induced Lung Injury occurs with over-distention of more compliant anterior lung segments and shear injury from repetitively opening and closing of less compliant posterior lung segments. This lung injury is exacerbated by the supine position directs ventilation more anteriorly while leaving the posterior lung atelectatic. The prone or lateral position improves the mal-distribution of tidal volume and reduces ARDS mortality.
Determining and Ordering Appropriate Resuscitation Status
Some have advocated eliminating the term DNR due to its confusion; for example, does it apply only post arrest? Although the answer is yes, poor or incomplete identification of patient goals of care coupled with a misunderstand of patient autonomy leads to prolonged suffering and increase cost with little benefit to the patient. We likely can do better, open the DOARS program
Pre-Op Optimization
Pre-op optimization” is replacing the term “Medical Clearance” as the best one can do is optimize the patient, particularly if it is non-elective. This program streamlines and improves the evaluation and improves optimization of hospitalized patients before surgery.
Peer Review
Hospital physician peer review is fundamental to improving patient care yet it is difficult to do well. See what are the problem and what can be done better to improve patient outcomes.