PubMed Health⌕ Search

Biomedical subjects

Deborah J Cook

Publications and source records attributed to Deborah J Cook.

At least 55 records · Page 3Linked to original sources
PubMed2004

Intravenous immunoglobulin for severe infections: a survey of Canadian specialists.

PURPOSE: To survey the opinions of Canadian critical care medicine and infectious disease specialists about the use of intravenous immunoglobulin (IVIG) for the treatment of severe infections. MATERIALS AND METHODS: A scenario-based, cross-sectional survey of Canadian critical care medicine and infectious disease specialists was conducted from March to June 2003. RESULTS: The response rate was 291/487 (60%). Respondents were primarily medically trained and most (241/291; 83%) were practicing in large academic referral centers. Physicians reported that they would use IVIG in patients with streptococcal toxic shock syndrome (STSS; 218/288; 76%), streptococcal necrotizing fasciitis without STSS (143/286; 50%), staphylococcal toxic shock syndrome (75/288; 26%), streptococcal soft tissue infection without NF or STSS (31/286; 11%), and septic shock due to intra-abdominal focus (9/283; 3%). The majority (> or =67%) of respondents believed that it would be ethical to randomize patients to IVIG or placebo in a clinical trial in each of the five scenarios. One third (192/286) reported that it would not be ethical to randomize patients with STSS. Canadian specialists commonly report favoring the use of IVIG to treat STSS and necrotizing fasciitis but less commonly endorse this treatment for other infections. CONCLUSION: Specialist's beliefs surrounding the efficacy of IVIG would challenge but not preclude the conduct of future placebo controlled trials of severe streptococcal infections in Canada.

Attitude of Health Personnel↗
PubMed2004

Safety and efficacy of low molecular weight heparins for hemodialysis in patients with end-stage renal failure: a meta-analysis of randomized trials.

Low molecular weight heparins (LWMH) are the preferred initial treatment for many thromboembolic disorders but are renally excreted and relatively contraindicated in patients with renal failure because of concerns of increased bleeding risks. The purpose of this study was to evaluate the safety and efficacy of LMWH compared with unfractionated heparin (UFH) for preventing thrombosis of the extracorporeal dialysis circuit. Studies were identified with the use of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and FirstSearch; reference lists were reviewed; and pharmaceutical companies were contacted. Randomized, controlled trials that compared an LMWH with another anticoagulant during hemodialysis in patients with ESRD and reported at least one of bleeding, extracorporeal circuit thrombosis, or anti-Xa levels were chosen. Two reviewers independently extracted data on methodologic quality, study design, clinical outcomes, and anti-Xa levels. Seventeen trials were included in this systematic review, 11 of which were included in the meta-analysis. It was found that LMWH did not significantly affect the number of bleeding events (relative risk, 0.96; 95% confidence interval [CI], 0.27 to 3.43), bleeding assessed by vascular access compression time (weighted mean difference, -0.87; 95% CI, -2.75 to 1.02), or extracorporeal circuit thrombosis (relative risk, 1.15; 95% CI, 0.70 to 1.91) as compared with UFH. LMWH seem to be as safe as UFH in terms of bleeding complications and as effective as UFH in preventing extracorporeal circuit thrombosis. However, inferences from these trials assessing anticoagulation for patients who undergo hemodialysis will continue to be weak until larger, more rigorous randomized trials are conducted.

Anticoagulants↗
PubMed2004

Survey of interventions for the prevention and treatment of acute respiratory distress syndrome.

OBJECTIVE: To determine physicians' opinions and practices related to the management of patients with acute respiratory distress syndrome. DESIGN: Cross-sectional mail survey. SETTING: Province of Ontario, Canada. PARTICIPANTS: Physicians treating patients with acute respiratory distress syndrome at university-affiliated and unaffiliated hospitals. INTERVENTIONS: We searched the literature and consulted experts to generate a list of potential interventions for acute respiratory distress syndrome. Eight intensive care unit physicians selected the most relevant, available, and controversial of these interventions for prevention (n = 5) and treatment (n = 30). Fourteen physicians reviewed the questionnaire before administration to ensure clarity, realism, and clinical sensibility. We asked participants to report their views on a) the efficacy of each intervention; b) published research evaluating efficacy; c) the frequency with which they use each intervention; and d) determinants of utilization. MEASUREMENTS AND MAIN RESULTS: One hundred ten of 194 eligible physicians responded. Respondents varied considerably in their reported use of the 35 interventions. Although physicians cited published research findings as the most powerful determinant of prescribing these interventions, they were unaware of many relevant trials. Physicians also commonly cited "usual local practice" as a determinant of use, although formal practice guidelines were rarely in operation. Other variables directly associated with use of these interventions included increasing frequency of exposure to acute respiratory distress syndrome (p <.0001), increasing size of the intensive care unit in which physicians work (p =.004), and the presence of residents in the intensive care unit (p =.02). CONCLUSIONS: Wide variation in the management of acute respiratory distress syndrome appears related to limited awareness of relevant research, conflicting interpretations of research findings, and adherence to varying local practice patterns. Given physicians' desire to tailor their practice to research findings and to practice in a manner that is consistent with their local intensive care unit colleagues, future research and educational efforts related to evidence-based protocols for the management of patients with acute respiratory distress syndrome might be worthwhile.

Adult↗
PubMed2004

Rationing critical care beds: a systematic review.

OBJECTIVE: Rationing critical care beds occurs daily in the hospital setting. The objective of this systematic review was to examine the impact of rationing intensive care unit beds on the process and outcomes of care. DATA SOURCE: We searched MEDLINE (1966-2003), CINAHL (1982-2003), Ovid Healthstar (1975-2003), EMBASE (1980-2003), Scisearch (1980-2003), the Cochrane Library, PUBMED related articles, personal files, abstract proceedings, and reference lists. STUDY SELECTION: We included studies of seriously ill patients considered for admission to an intensive care unit bed during periods of reduced availability. We had no restriction on study design. Studies were excluded if rationing was performed using a scoring system or protocol and if cost-effectiveness was the only outcome. DATA EXTRACTION: In duplicate and independently, we performed data abstraction and quality assessment. DATA SYNTHESIS: We included ten observational studies. Hospital mortality rate was increased in patients refused intensive care unit admission vs. those admitted (odds ratio, 3.04; 95% confidence interval, 1.49-6.17). Factors associated with both intensive care unit bed refusal and increased mortality rate were increased age, severity of illness, and medical diagnosis. When intensive care unit beds were reduced, admitted patients were sicker, were less often admitted primarily for monitoring, and had a shorter intensive care unit length of stay, without other observed adverse effects. CONCLUSIONS: These studies suggest that patients who are perceived not to benefit from critical care are more often refused intensive care unit admission; refusal is associated with an increased risk of hospital death. During times of decreased critical bed availability, several factors, including age, illness severity, and medical diagnosis, are used to triage patients, although their relative importance is uncertain. Critical care bed rationing requires further investigation.

Adolescent↗
PubMed2004

Translating family satisfaction data into quality improvement.

BACKGROUND: Improvement of clinical care requires measurement of key dimensions of health care quality and action based on these measurements. Families, data analysts, clinicians, and administrators all have important roles to play. OBJECTIVE: To outline an approach to the measurement and utilization of family satisfaction data so that these data can be translated into health care quality improvement initiatives. DESIGN: Using a synthesis of existing knowledge about translation of satisfaction data into improvement strategies, this approach starts with selecting and implementing a satisfaction survey that reflects the key processes, providers, and places for the delivery of critical care. The survey results can be expressed in a way that prioritizes the opportunities for improvement. A comparison of results across sites, or use of a performance-importance grid, can assist in this prioritization process. High-priority items can then be addressed by the multidisciplinary intensive care unit team using a systematic, evidence-based approach to improvement that includes implementation strategies that have been proven to effectively change clinician behavior.

Consumer Behavior↗
PubMed2004

Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review.

CONTEXT: The results of studies on noninvasive positive pressure ventilation (NPPV) for acute hypoxemic respiratory failure unrelated to cardiogenic pulmonary edema have been inconsistent. OBJECTIVE: To assess the effect of NPPV on the rate of endotracheal intubation, intensive care unit and hospital length of stay, and mortality for patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema. DATA SOURCE: We searched the databases of MEDLINE (1980 to October 2003) and EMBASE (1990 to October 2003). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. STUDY SELECTION: We included studies if a) the design was a randomized controlled trial; b) patients had acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema; c) the interventions compared noninvasive ventilation and standard therapy with standard therapy alone; and d) outcomes included need for endotracheal intubation, length of intensive care unit or hospital stay, or intensive care unit or hospital survival. DATA EXTRACTION: In duplicate and independently, we abstracted data to evaluate methodological quality and results. DATA SYNTHESIS: The addition of NPPV to standard care in the setting of acute hypoxemic respiratory failure reduced the rate of endotracheal intubation (absolute risk reduction 23%, 95% confidence interval 10-35%), ICU length of stay (absolute reduction 2 days, 95% confidence interval 1-3 days), and ICU mortality (absolute risk reduction 17%, 95% confidence interval 8-26%). However, trial results were significantly heterogeneous. CONCLUSION: Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations. As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure.

Adult↗
PubMed2004

Management of the critically ill patient with severe acute pancreatitis.

OBJECTIVE: Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP). DATA SOURCES AND METHODS: An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis. DATA SYNTHESIS: There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas. CONCLUSIONS: This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.

Acute Disease↗
PubMed2003

Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature.

BACKGROUND: Over the past decade, noninvasive positive-pressure ventilation (NPPV) in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased in popularity. Although several trials have been published on the relative effectiveness of this treatment, apparent inconsistencies in study results remain. PURPOSE: To assess the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality rate in patients with an acute exacerbation of COPD and to determine the effect of exacerbation severity on these outcomes. DATA SOURCES: MEDLINE (1966 to 2002) and EMBASE (1990 to 2002). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. There were no language restrictions. STUDY SELECTION: The researchers selected randomized, controlled trials that 1) examined patients with acute exacerbation of COPD; 2) compared noninvasive ventilation and standard therapy with standard therapy alone; and 3) included need for endotracheal intubation, length of hospital stay, or hospital survival as an outcome. DATA EXTRACTION: Methodologic quality and results were abstracted independently and in duplicate. DATA SYNTHESIS: The addition of NPPV to standard care in patients with an acute exacerbation of COPD decreased the rate of endotracheal intubation (risk reduction, 28% [95% CI, 15% to 40%]), length of hospital stay (absolute reduction, 4.57 days [CI, 2.30 to 6.83 days]), and in-hospital mortality rate (risk reduction, 10% [CI, 5% to 15%]). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations. CONCLUSIONS: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.

Hospital Mortality↗
PubMed2003

A systematic review of economic analyses of low-molecular-weight heparin for the treatment of venous thromboembolism.

INTRODUCTION: Public concerns about the increase in health care expenditure have prompted investigators to analyze the costs and benefits of health care interventions. We conducted a systematic review of economic analyses of venous thromboembolism treatment focusing on studies evaluating low-molecular-weight heparin. MATERIALS AND METHODS: We identified studies by a MEDLINE search and a review of bibliographies of retrieved articles. From each eligible study, we extracted data on the study characteristics, the effectiveness, and the cost of managing the venous thromboembolism with respect to treatment. We critically appraised the studies according to the framework from the Users' Guides to the Medical Literature XIII: How to Use an Article on Economic Analysis of Clinical Practice. RESULTS: Six of these eight economic analyses of venous thromboembolism treatment that met the inclusion criteria for this review showed that low-molecular-weight heparin is associated with less recurrent venous thromboembolism and is less costly than treatment with unfractionated heparin. Although discrete recurrent venous thromboembolism event rates were not included in the seventh study, these investigators concluded that the cost of low-molecular-weight heparin for the treatment of venous thromboembolism treatment was offset by the savings associated with fewer hospital admissions when low-molecular-weight heparin was used. In the eighth study, although the cost of treatment with low-molecular-weight heparin was higher than treatment with unfractionated heparin, the investigators concluded that low-molecular-weight heparin is cost-effective for inpatient management. CONCLUSIONS: Low-molecular-weight heparin treatment may confer economic advantages over unfractionated heparin therapy because it does not require anticoagulant monitoring and it facilitates outpatient therapy.

Anticoagulants↗
PubMed2003

Procalcitonin as a diagnostic test for sepsis: health technology assessment in the ICU.

Elevation in the serum concentration of procalcitonin (PCT) is associated with systemic infection. This association has led to the proposed use of PCT as a novel biomarker of bacterial sepsis. The advantages and limitations of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) definitions of sepsis are an important consideration that affects the impact of any diagnostic test for sepsis and these issues are discussed. Our main objective is to perform a systematic health technology assessment of PCT as a diagnostic test for sepsis. In an adult intensive care unit (ICU) population, we identify a specific and important question-can PCT accurately distinguish sepsis in patients with systemic inflammatory response syndrome (SIRS) who have a suspected infection? Likelihood ratios are calculated from published data to attempt to find the best answer. The published evidence does not support a general claim that PCT is a useful decision support tool for diagnosing sepsis in patients who have SIRS. Procalcitonin has a slightly better ability to exclude the diagnosis of sepsis. The role for using PCT testing in the ICU will continue to evolve along with our understanding and definition of sepsis.

Biomarkers↗
PubMed2003

Health technology assessment in the ICU: noninvasive positive pressure ventilation for acute respiratory failure.

Critical care practitioners have a number of health-related technologies at our disposal to provide the best possible care for our critically ill patients. Although certain technologies may improve outcomes in the intensive care unit (ICU), many technologies are disseminated without rigorous evaluation. Health technology assessment (HTA) in critical care is a complex and dynamic process, which is a powerful tool to assess a health technology for its initial use or continued application in the ICU. This article applies an HTA framework to the use of noninvasive positive pressure ventilation (NPPV) for patients with acute respiratory failure (ARF). The strongest evidence to date supports the use of NPPV in patients with ARF caused by exacerbations of chronic obstructive pulmonary disease (COPD); the benefit for patients with acute nonhypercarbic, hypoxemic respiratory failure is less clear. The success of NPPV technology depends on operator education and experience. The cost effectiveness of NPPV has been evaluated in patients with ARF caused by COPD, and cost reduction is attributed to the prevention of ventilator-associated pneumonia by avoiding endotracheal intubation. An HTA framework can help health care practitioners make important decisions regarding the acquisition of new technologies and the evaluation of current technologies. Careful evaluation of health technologies in the ICU should be an ongoing priority.

Acute Disease↗
PubMed2003

Seasonal bed closures in an intensive care unit: a qualitative study.

OBJECTIVE: To describe perceptions of the administrative procedures for seasonal bed closures and their consequences in the intensive care unit (ICU), and to critique this example of health care priority setting for legitimacy and fairness. DESIGN: A qualitative study using case study methods and interviews with key participants. We evaluated fairness and legitimacy of the bed closure process using 4 domains of the ethical framework of "accountability for reasonableness." SETTING: An university-affiliated medical/surgical ICU in Eastern Canada. PARTICIPANTS: ICU clinicians (9 bedside nurses and 5 physicians), and administrators (3 ICU managers and 2 senior hospital executives). MAIN OUTCOME MEASURES: Perceptions of ICU clinicians and administrators regarding the ICU bed closure decision-making process and its consequences. RESULTS: Emerging themes concerned: (1) bed closure rationale (including arbitrary decision making, bed closure masquerading as a code for a nursing shortage, and suboptimal evidence base for implementing closures); (2) bed closure process (viewed as unclear with insufficient prior publicity and inadequate subsequent review); and (3) adverse consequences (including safety issues, negative professional working relationships, and poor morale). Although an appeals mechanism existed, nurses were not available to staff reopened beds so this condition is only partially met. The relevance, publicity, and enforcement conditions for accountability of reasonableness were not satisfied, offering opportunities for improvement. CONCLUSION: Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU. These shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.

Decision Making↗
PubMed2003

Prognostic value of myocardial perfusion studies in patients with end-stage renal disease assessed for kidney or kidney-pancreas transplantation: a meta-analysis.

The prognostic utility of myocardial perfusion studies (MPS) such as thallium scintigraphy and dobutamine stress echocardiography (DSE) for stratifying cardiac risk among candidates for kidney or kidney-pancreas transplantation is uncertain. This study is a meta-analysis to determine the prognostic significance of MPS results on future myocardial infarction (MI) and cardiac death (CD) in patients with end-stage renal disease (ESRD) assessed for kidney or kidney-pancreas transplantation. MEDLINE was searched using combinations of MeSH headings and text words for transplantation, coronary artery disease, prognosis, end-stage renal disease, and noninvasive cardiac testing (nuclear scintigraphy and DSE) for primary studies. Studies were included if they reported MPS results and cardiac events in patients assessed for kidney or kidney-pancreas transplantation. Methodologic study quality and outcome data were independently abstracted in duplicate by two researchers. The relative risks (RR) of MI and CD were calculated using a random effects model. Twelve articles met all inclusion criteria; 12 studies reported CD, and 9 reported MI. In eight studies, thallium scintigraphy was used (four with pharmacologic stress, four with exercise stress), whereas four used DSE. When compared with negative tests, positive tests had a significantly increased RR of MI (2.73 [95% CI, 1.25 to 5.97]; P = 0.01) and CD (2.92 [95% CI, 1.66 to 5.12]; P < 0.001). Subgroup analyses of studies of diabetic patients indicated that positive tests were associated with a RR of CD 3.95 (95% CI, 1.48 to 10.5; P = 0.006) and a RR of MI 2.68 (95% CI, 0.95 to 7.57; P = 0.06) when compared with negative tests. In studies evaluating mixed populations of diabetic and nondiabetic patients, positive tests were associated with a RR of CD 2.52 (95% CI, 1.25 to 5.08; P = 0.01) and with a RR of MI 2.79 (95% CI, 0.85 to 9.21; P = 0.09) when compared with a negative test. The presence of reversible defects was associated with an increased risk of MI in diabetic patients and of CD in both subgroups; fixed defects were associated with an increased risk of CD but not MI. It is concluded that positive MPS are useful in identifying patients with significantly increased risk of future MI and CD in both diabetic and nondiabetic ESRD patients.

Coronary Circulation↗
PubMed2003

Methodologic issues in systematic reviews and meta-analyses.

Systematic reviews of original research are increasing in number. Systematic reviews are distinct from narrative reviews because they address a specific clinical question, require a comprehensive literature search, use explicit selection criteria to identify relevant studies, assess the methodologic quality of included studies, explore differences among study results, and either qualitatively or quantitatively synthesize study results. Systematic reviews that quantitatively pool results of more than one study are called meta-analyses. Several organizations are collaboratively involved in producing high quality systematic reviews and meta-analyses. Familiarity with how to do a systematic review and meta-analysis will lead to greater skill in using this type of article. For clinicians, teachers, and investigators, systematic reviews and meta-analyses are useful sources of evidence.

Decision Making↗
PubMed2003

Measures, markers, and mediators: toward a staging system for clinical sepsis. A report of the Fifth Toronto Sepsis Roundtable, Toronto, Ontario, Canada, October 25-26, 2000.

BACKGROUND: Sepsis is not a single disease but a complex and heterogeneous process. Its expression is variable, and its severity is influenced by the nature of the infection, the genetic background of the patient, the time to clinical intervention, the supportive care provided by the clinician, and a number of factors as yet unknown. The evaluation of effective therapies has been hampered by limitations in our ability to characterize the process and to stratify patients into more homogeneous groups with respect to pathogenesis. OBJECTIVES: To develop a taxonomy of markers relevant to clinical research in sepsis and to propose a testable candidate system for stratifying patients into more therapeutically homogeneous groups. DATA SOURCE: An expert roundtable discussion and a MEDLINE review using search terms "marker" and "sepsis." RESULTS: Markers provide information in one or more of three domains: diagnosis, prognosis, and response to therapy. More than 80 putative markers of sepsis have been described. All correlate with the risk of mortality (prognosis), yet none has shown utility in stratifying patients with respect to therapy (diagnosis) or in titrating that therapy (response). Their limitations arise from the challenges of establishing causality in a complex disease process such as sepsis and of stratifying patients into more homogeneous populations. The former limitation may be addressed through a modification of Koch's postulates to differentiate causality from simple association. The latter suggests the need for a staging system analogous to those used in other complex disease processes such as cancer. A candidate framework for such a system, based on the infection, the host response, and the extent of organ dysfunction (the IRO system) is described. CONCLUSIONS: Advances in the understanding and management of patients with sepsis will necessitate more rigorous approaches to disease description and stratification. Models should be developed, tested, and modified through clinical studies rather than through consensus.

Biomarkers↗
PubMed2003

Evaluation of a practice guideline for noninvasive positive-pressure ventilation for acute respiratory failure.

OBJECTIVES: Clinical practice guidelines have been devised to change practitioner performance and to improve the process and outcomes of care. The objective of this study was to determine whether adherence to a practice guideline on noninvasive positive-pressure ventilation (NPPV) for the treatment of patients with acute respiratory failure (ARF) would change clinician behavior and resource utilization, and improve NPPV utilization and patient outcomes. DESIGN: Using a multidisciplinary team, we developed, implemented, and evaluated an NPPV practice guideline for ARF. Before and after guideline implementation, we recorded the incidence of endotracheal intubation (ETI) and mortality. Secondary outcomes were technological settings (ie, NPPV settings and duration) and NPPV administration (ie, cardiopulmonary monitoring, transfer to and time spent in the ICU, and pulmonary consultation). PARTICIPANTS: We enrolled 189 patients, 91 in the preguideline phase and 98 in the postguideline phase. Patients were similar in the both phases with respect to diagnoses at hospital admission and severity of illness. RESULTS: Of patients receiving NPPV for ARF, 67.3% fulfilled the guideline eligibility criteria in the postguideline phase compared to 62.6% in the preguideline phase (p = 0.543). Compared to the preguideline phase, more patients in the postguideline phase were transferred to the ICU (14.7% vs 33.7%, respectively; p = 0.003), spent more time in the ICU (30.9% vs 62.4%, respectively; p < 0.0001), and had consultation by a pulmonary physician (28.4% vs 49.0%, respectively; p = 0.004). There were no changes in technological settings. Guideline implementation was associated with improved cardiopulmonary monitoring. Nursing and respiratory therapist flow sheets were well-utilized during the guideline phase. There were no differences in ETI rates and mortality rates before and after guideline implementation. CONCLUSION: In this before-after study, we found that a multidisciplinary guideline for the use of NPPV for the treatment of patients with ARF was associated with changes in the process of care, with greater NPPV utilization in the ICU, and with increased pulmonary consultation, without any significant changes in the outcomes of care (ie, ETI and mortality rates).

Acute Disease↗