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Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine; Director, Medical Intensive Care Unit, Barnes Jewish Hospital; and Director, Respiratory Care Services, Barnes Jewish Hospital.
Correspondence to: Marin H. Kollef, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Campus Box 8052, 660 South Euclid Avenue, St. Louis, MO 63110; e-mail: mkollef@pulmonary.wustl.edu
The complexity of patients cared for in modern ICUs, along with continuing advances in the technology of critical care and the escalating costs associated with providing that care, have been factors motivating critical care practitioners to identify and implement "best" medical practices.1 Individual best practices are often determined based on their association with improvements in patient outcomes, increased efficiency and cost-effectiveness of medical care, or both of these criteria. These practices should ideally be determined based on sound medical evidence obtained from rigorously performed clinical trials, the most rigorous being randomized controlled trials. However, such trials have often not been performed for many aspects of critical care medicine, including the optimal utilization of neuromuscular blocking agents in the ICU setting. Outcomes research is an emerging field that attempts, in part, to use variations in medical practices to identify important associations between such practices and clinical outcomes.2 As reported in this issue of CHEST (see page 1627), Behbehani and coworkers performed a retrospective cohort study to determine the incidence of acute myopathy in asthma patients requiring mechanical ventilation at two medical centers in Vancouver, Canada.
In the 86 patients who were evaluated, there were 94 episodes of near-fatal asthma requiring mechanical ventilation. Based on their study results, a total of nine patients (10.5%) developed myopathy. The incidence of myopathy was significantly greater in patients receiving neuromuscular blocking agents than in patients not receiving these agents: 30% vs 0%, respectively (p < 0.001). A multivariate analysis demonstrated that the duration of neuromuscular blocking agent administration was the only variable significantly associated with the development of myopathy. Although similar findings have been demonstrated previously by other investigators,3 ,4 ,5 Behbehani et al also showed that the occurrence of myopathy varied between the two hospitals examined. This discrepancy, to a large extent, appeared to be due to the different ways that the neuromuscular blocking agents were used at the two centers. One center had 8 of 20 patients (40%) develop myopathy after receiving neuromuscular blocking agents, while the other center had only 1 of 10 patients (10%) develop this same complication after receiving these agents (p = 0.09).
The most obvious explanation for the difference in the occurrence of myopathy between these two institutions is provided by the discussion in the article. The hospital with the greater occurrence of myopathy primarily administered the neuromuscular blocking agents as continuous IV infusions, while the other hospital appeared to administer them as intermittent boluses. This resulted in a longer duration of administration at the center with the greater rate of myopathy: 3.8 ± 2.3 vs 2.0 ± 1.6 days (p = 0.04). The relatively small sample size of this investigation probably accounted for the authors' inability to identify the treating center as a variable independently associated with the occurrence of myopathy in their multivariate analysis. Indeed, it appears that the main finding of this investigation is the identification of a variation in practice between the two study institutions, suggesting that continuous IV administration of neuromuscular blocking agents should be avoided. An important extension of these findings would be to show that the practices changed at the hospital with the greater incidence of myopathy (ie, a decreased utilization of continuous IV administration of neuromuscular blocking agents), resulting in a lower incidence of this complication.
Other investigators have relied on similar types of comparative outcome studies to identify optimal medical practices at specific institutions. These studies have focused on outcomes such as hospital mortality, ICU resource utilization, and the occurrence of specific complications.6 ,7 ,8 Similarly, studies performed at single institutions using before-after study designs have attempted to identify the benefits or potential harms of practice changes between two different time periods.9 ,10 ,11 In general, these studies lack the rigor of randomized controlled trials because of the absence of randomly selected concurrent control groups exposed to the same study conditions; however, they do provide the local medical community with potentially important clinical data regarding their own unique environments. When compared to clinical studies performed at outside institutions, these locally performed studies may also assist hospitals in implementing practice changes, by more readily facilitating buy-in from practitioners.
The potential benefits of having similar types of data available for other institutions cannot be underemphasized. Although report cards for hospitals are becoming increasing popular,12 they do not necessarily convey useful information regarding the individual practices within those institutions. Moreover, such report cards usually do not provide appropriate data for carrying out improvements or for testing the impact of practice changes on clinical outcomes. Several attempts at implementing large-scale quality improvements or practice changes in the hospital setting recently have been made. The results of specific evaluations and comparisons of heart surgery in parts of New England and New York have led to changes in practices within individual hospitals that resulted in improved clinical outcomes.13 ,14 Similarly, private organizations such as the Institute for Healthcare Improvement have attempted to produce similar improvements in practices at the individual institutional level.15 ,16
At the present time, there are no systematic approaches available for the comparison of practices and outcomes within ICUs across the United States. Project IMPACT, supported by the Society of Critical Care Medicine, has attempted to be a first step in providing such an approach to quality improvement. Future clinical investigation should reveal if such databases can help identify institutions with the best practices and outcomes and thereby stimulate change in institutions having inferior medical practices and outcomes. Until that time, local efforts should continue to be undertaken to improve the quality of medical care at the individual hospital level, using either historical controls (ie, before-after study design) or other available databases for comparison. Only by carrying out such efforts can we hope to maintain the quality of medical care in our ICUs under current cost-cutting pressures.17
References
This article has been cited by other articles:
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  D. Johnson and I. Mayers Multiple organ dysfunction syndrome: a narrative review Can J Anesth, May 1, 2001; 48(5): 502 - 509. [Abstract] [Full Text] [PDF]
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 A. D. Brook and M. H. Kollef An Outcomes-Based Approach to Ventilatory Management: Review of Two Examples: Brook AD, Kollef MH An outcomes-based approach to ventilatory management review of two examples J Intensive Care Med 1999,14 262-274 J Intensive Care Med, November 1, 1999; 14(6): 262 - 274. [PDF]
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