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Biomedical subjects

Alan H Morris

Publications and source records attributed to Alan H Morris.

9 recordsLinked to original sources
PubMed2004

Clinical trial of a weaning protocol.

Krishnan and colleagues have conducted a prospective clinical trial of a weaning strategy previously demonstrated to enhance clinical outcomes of mechanically ventilated patients. They draw conclusions quite different from those drawn in an accompanying editorial. Krishnan and colleagues compared the outcomes of patients supported with mechanical ventilation for at least 24 hours. The outcome of those patients weaned from mechanical ventilation was compared with the outcome of those patients who received usual care. Although usual care was not defined, it was delivered in an unusual environment that included many systems improvement elements previously demonstrated to improve clinical outcomes. The investigators worked in a closed intensive care unit that employed large numbers of physicians (six residents, two postdoctoral fellows, and two attending physicians for a 14-bed unit), and used a structured standard checklist to make patient review during rounds more systematic. These features might reduce the difference in outcome between the protocol group and other patients in their unit. In addition, the experimental design allowed convergence of the method of care of protocol group patients with the method of care of other patients. Their results are compatible with either no effect of the protocol or with an inability to demonstrate the effect of the protocol because of the systems improvement elements in operation in their intensive care unit.

Clinical Protocols↗
PubMed2003

Treatment algorithms and protocolized care.

PURPOSE OF REVIEW: 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. RECENT FINDINGS: 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. SUMMARY: 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.

Algorithms↗
PubMed2003

The changing face of organ failure in ARDS.

OBJECTIVE: To study morbidity and mortality in ARDS patients from 1987 to 1999. DESIGN: Review of a prospectively collected database of ARDS patients. SETTING: Large, community hospital located in Salt Lake City, UT. PATIENTS: ARDS patients identified for the years 1987 to 1999. We prospectively identified ARDS patients at LDS Hospital in Salt Lake City, UT, using PaO(2)/fraction of inspired oxygen ratio (P/F) criteria, the presence of bilateral chest radiograph infiltrates, and the absence of left atrial hypertension. MEASUREMENTS: We assigned a primary risk factor for ARDS and identified the presence of organ failure before and after ARDS. We compared two temporal groups (ie, 1987 to 1990 vs 1994 to 1999) and used two criteria of arterial hypoxemia (P/F: patients from 1994 to 1999, < or = 105 and < or = 173; patients from 1987 to 1990, < or = 0.2) At 1,500 m (the altitude of Salt Lake City), a PaO(2) of < or = 173 corresponds to an alveolar-arterial oxygen pressure difference of < or = 200 at sea level. We used death at hospital discharge as an end point. MAIN RESULTS: We identified 516 ARDS patients with a P/F of < or = 105 (1987 to 1990, 256 patients; 1994 to 1999, 260 patients). Patients who had ARDS between 1994 and 1999 with a P/F of < or = 105 had a lower mortality rate than patients between 1987 and 1990 with a P/F of < or = 105 (44% vs 54%, respectively; p <.05). There were 288 patients with a P/F range of 106 to 173 during 1994 to 1999. Patients from 1994 to 1999 with a P/F of < or = 173 had a lower mortality rate compared to patients from 1987 to 1990 (35% vs 54%, respectively; p <.01). Patients from 1994 to 1999 (for both P/F groups) had statistically fewer total nonpulmonary organ failures (ie, more patients had zero organ failures or single organ failures) and fewer specific organ failures (ie, sepsis, cardiovascular failures, and CNS failures). There were statistically fewer cases of cardiovascular failure, sepsis, and in both periods (ie, prior to ARDS and after the onset of ARDS) for 1994-to-1999 patients with a P/F of < or = 105 compared to 1987-to-1990 patients with a P/F of < or = 105. CONCLUSIONS: Mortality from ARDS has decreased and is associated with decreased organ failure prior to and during the course of ARDS.

Female↗
PubMed2003

Cognitive evaluation of the predictors of use of computerized protocols by clinicians.

We describe a cognitive approach to evaluating the factors that motivate clinicians to use computerized protocols. Using Value-Expectancy theories we developed an open-ended interview to assess clinicians' beliefs and experiences about the use of computerized protocols. Using a qualitative methodology, 3 reviewers independently identified key concepts raised by 13 interviewees. These concepts were aggregated and independently sorted into 39 categories. Then final categories were chosen by consensus. Analysis of the concepts showed consistency across clinician specialties of physicians, nurses and respiratory therapists. Inter-rater reliability calculated using Cohen's Kappa was 0.474. Identified constructs from Value-Expectancy and Intrinsic Motivation theories were: Work Importance, Perception of Situation, Role Relevance, Beliefs regarding Control, Beliefs regarding Normative Expectations, Beliefs regarding Self-Efficacy, Attitude, Habit, Environmental Support and Pre-Behavior. This model will form the basis for an instrument to assess the beliefs and expectations of clinical use regarding the use of computerized protocols.

Attitude of Health Personnel↗
PubMed2002

Hyperbaric oxygen for acute carbon monoxide poisoning.

BACKGROUND: Patients with acute carbon monoxide poisoning commonly have cognitive sequelae. We conducted a double-blind, randomized trial to evaluate the effect of hyperbaric-oxygen treatment on such cognitive sequelae. METHODS: We randomly assigned patients with symptomatic acute carbon monoxide poisoning in equal proportions to three chamber sessions within a 24-hour period, consisting of either three hyperbaric-oxygen treatments or one normobaric-oxygen treatment plus two sessions of exposure to normobaric room air. Oxygen treatments were administered from a high-flow reservoir through a face mask that prevented rebreathing or by endotracheal tube. Neuropsychological tests were administered immediately after chamber sessions 1 and 3, and 2 weeks, 6 weeks, 6 months, and 12 months after enrollment. The primary outcome was cognitive sequelae six weeks after carbon monoxide poisoning. RESULTS: The trial was stopped after the third of four scheduled interim analyses, at which point there were 76 patients in each group. Cognitive sequelae at six weeks were less frequent in the hyperbaric-oxygen group (19 of 76 [25.0 percent]) than in the normobaric-oxygen group (35 of 76 [46.1 percent], P=0.007), even after adjustment for cerebellar dysfunction and for stratification variables (adjusted odds ratio, 0.45 [95 percent confidence interval, 0.22 to 0.92]; P=0.03). The presence of cerebellar dysfunction before treatment was associated with the occurrence of cognitive sequelae (odds ratio, 5.71 [95 percent confidence interval, 1.69 to 19.31]; P=0.005) and was more frequent in the normobaric-oxygen group (15 percent vs. 4 percent, P=0.03). Cognitive sequelae were less frequent in the hyperbaric-oxygen group at 12 months, according to the intention-to-treat analysis (P=0.04). CONCLUSIONS: Three hyperbaric-oxygen treatments within a 24-hour period appeared to reduce the risk of cognitive sequelae 6 weeks and 12 months after acute carbon monoxide poisoning.

Acute Disease↗