EditorialIs failure to awaken and wean malpractice?
Section snippets
Awaken-and-wean saves lives: a selective review of the evidence
Ely et al pioneered the idea that systematic testing of patients' readiness for liberation from mechanical ventilation yields superior results to traditional physician-directed weaning [2]. In their landmark study, 149 patients randomized to have spontaneous breathing trials (SBTs) administered automatically by respiratory therapists, after meeting objective cardiorespiratory criteria of stability, were successfully extubated a median of 1.5 days sooner than 151 patients weaned only when
Theoretical considerations
Salient arguments can be made regarding the certitude of medical practices; that even with accumulation of “level 1” data, we rarely reach absolute certainty regarding the efficacy of medical practices and must discern—each to his own threshold—when there is sufficient evidence to apply advances [8]. Others have argued that studies applied to large groups are not necessarily applicable to individual patients. In my estimation, the latter—albeit intellectually accurate—ignores clinical reality
Is there evidence that patients remain on ventilators longer than necessary?
There is no direct evidence that clinicians fail to provide daily awaken-and-wean to patients. What about indirect evidence? We reported results of mechanically ventilated patients treated in our medical and surgical intensive care units (ICUs) between 2003 and 2009, real-world results in an inner city, teaching hospital [15]. Although results of a single center cannot be safely generalized, this is a large practical study of outcomes of mechanically ventilated patients. Patients in the medical
Solutions
If we accept that many patients remain on ventilators longer than necessary, that shorter is better, and that awaken-and-wean is a proven method to reduce duration and improve outcomes, what measures might close this quality chasm? Clinicians' behaviors are difficult to change, so no single intervention is likely to achieve universal deployment of this (and other) lifesaving treatments. Greater use of awaken-and-wean and other high-stake, highly beneficial treatments could be driven by some
Conclusion
A great deal of time, effort, and money has been invested in making medicine more like civil aviation, that is, to require “high reliability” and best, safe practices. For whatever reasons, physicians have been slow to embrace these principles. Yet, to not provide treatments that reduce patients' suffering should not be permissible; systemic failures should be confronted and corrected. We need to inculcate this idea in our students and help policymakers and hospital leaders craft incentives
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Cited by (1)
Don't turn-off the brain
2019, Medicina Intensiva
The author has no relevant conflicts of interest and receives no external funding.