Treatment algorithms and protocolized care.
OBJECTIVE
Excess information in complex ICU environments exceeds human decision-making limits and likely contributes to unnecessary variation in clinical care, increasing the likelihood of clinical errors. I reviewed recent critical care clinical trials searching for information about the impact of protocol use on clinically pertinent outcomes.


RESULTS
Several recently published clinical trials illustrate the importance of distinguishing efficacy and effectiveness trials. One of these trials illustrates the danger of conducting effectiveness trials before the efficacy of an intervention is established. The trials also illustrate the importance of distinguishing guidelines and inadequately explicit protocols from adequately explicit protocols. Only adequately explicit protocols contain enough detail to lead different clinicians to the same decision when faced with the same clinical scenario.


CONCLUSIONS
Differences between guidelines and protocols are important. Guidelines lack detail and provide general guidance that requires clinicians to fill in many gaps. Computerized or paper-based protocols are detailed and, when used for complex clinical ICU problems, can generate patient-specific, evidence-based therapy instructions that can be carried out by different clinicians with almost no interclinician variability. Individualization of patient therapy can be preserved by these protocols when they are driven by individual patient data. Explicit decision-support tools (eg, guidelines and protocols) have favorable effects on clinician and patient outcomes and can reduce the variation in clinical practice. Guidelines and protocols that aid ICU decision makers should be more widely distributed.
Morris
Alan H
AH
Department of Medicine, LDS Hospital and University of Utah School of Medicine, Salt Lake City, Utah 84143, USA. ldamorri@ihc.com
D000465:Algorithms; D001786:Blood Glucose / Q000032:analysis; D002249:Carbon Monoxide Poisoning / Q000628:therapy; D002407:Catheterization, Swan-Ganz / Q000592:standards; D002985:Clinical Protocols; D003422:Critical Care / Q000592:standards*; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000592:standards; D006801:Humans; D006931:Hyperbaric Oxygenation / Q000592:standards; D006943:Hyperglycemia / Q000188:drug therapy; D007328:Insulin / Q000627:therapeutic use; D011175:Positive-Pressure Respiration / Q000592:standards; D017410:Practice Guidelines as Topic; D012772:Shock, Septic / Q000628:therapy
D001786:Blood Glucose; D007328:Insulin