Medical care for the critically ill usually advances in an incremental fashion. Physicians, for the most part, are a conservative group and critical care physicians are an important subgroup that tends to value a scientific approach and evidence-based decision-making. Experimental evidence requires time to generate, appropriate vetting through the peer review process, and then additional time prior to becoming engrained in clinical practice at the bedside for the benefit of patients. As a result, it is only through retrospective evaluation that the improvements in intensive care unit (ICU) care can be seen.
There are several important and relatively recent examples of this incremental approach in critical care, including low-tidal-volume ventilation, the management of hyperglycemia, and the use of hypertonic saline for acute elevations in intracranial pressure. Despite these well-defined examples, critically ill patients benefit from these approaches to a lesser degree than expected because their physicians fail to prescribe them in a large proportion of cases, thus compromising the quality of care for these critically ill patients. This is one example of how physicians can improve their own work by focusing on the elements of physician decision-making, particularly the process steps, and aligning them with the patients' needs.
Rarely, the quality of care for patient populations undergoes a major shift that can be thought of as revolutionary rather than evolutionary. These shifts, when viewed retrospectively, have usually involved major technological advances. For example, the use of fiberoptics in medicine has revolutionized the care of patients requiring diagnostic and therapeutic procedures. These patients now undergo relatively minor interventions as compared to what would have been experienced just a few decades ago. These shifts also involve practice settings. Surgeries formerly performed on inpatients are now performed on an ambulatory basis. Finally, these shifts involve physicians from different disciplines. Interventional radiologists are now performing procedures that previously required a surgeon. Cardiologists are now treating coronary syndromes in ways that previously required cardiac surgery.
Ultrasound use in the ICU is one such shift that decades from now will be viewed retrospectively as a revolutionary phenomenon that advanced the care of critically ill patients. However, the current challenge is to think prospectively, not retrospectively, about implementing this proven technology for diagnostic and therapeutic decision-making in a practice setting that is outside of the radiology suite and by providers who are neither radiologists nor cardiologists while the evidence base and applications are being further established. This book provides an opportunity to consider methods of applying this tool, in a thoughtful manner, at the bedside to advance the quality of care for this vulnerable subgroup of patients. Through an approach that evaluates the risks and benefits of using ultrasound in the ICU, physicians will be better able to understand how this technology can influence the care of their ICU patients.
Over the last 30 years, increased attention has been paid to the issues of quality health care. Donabedian provided a useful paradigm ...