Lựa chọn khôn ngoan trong điều trị tích cực tim mạch cái gì có lợi, cái gì không

14th Vietnam National Congress of Cardiology Da Nang, Vietnam October 11-14, 2014 Choosing Wisely in the ICU What Works and What Doesn’t Gregory W Barsness, MD, FACC, FAHA, FSCAI Director, Mayo Clinic Cardiac Intensive Care Unit Director, Mayo Clinic EECP Laboratory ©2013 MFMER | slide-1 Disclosures No pertinent financial conflicts ©2013 MFMER | slide-2 Learning Objectives • Identify Top ICU practices that DON’T work • Costly • Ineffective or harmful • Ethical practice concerns • Identify high-yield strategies that DO benefit ICU patients • Patient Activation and Adherence • Understand the systems approach to optimizing ICU care ©2013 MFMER | slide-3 Process Adherence and Outcome In-hosp mortality (%) 5.95 5.16 Adjusted Unadjusted 6.33 5.07 4.97 4.63 4.16 4.17 Every 10%  in guidelines adherence 11%  in mortality =75% Hospital composite quality quartiles Peterson, et al ACC 2004 ©2013 MFMER | slide-4 Things That Don’t Work in ICU Choosing Wisely Campaign • Much of current US care is duplicative, unnecessary and/or potentially harmful • Up to 30% of care activities may not improve patient health or well-being • Partnership between ABIM and Consumer Reports • Assist physicians and patients to identify overuse • Lessons learned applicable to developing systems • Avoid waste, increase quality • Able to shift resources to priority health needs • Collaborative use of limited resources ©2013 MFMER | slide-5 ©2013 MFMER | slide-6 Excessive Testing Imperative to Reduce Waste • Common diagnostic tests often ordered at recurring intervals (rather than as necessary) • CXR, ECG, WBC, serum chemistries • Increases costs without benefit and may lead to harm • Excessive phlebotomy, nutritional issues • “False” positives • Statistical boundaries (95% CI) • Unnecessary evaluation of non-pathological test results with associated morbidity • “Test only when the result matters” ©2013 MFMER | slide-7 ©2013 MFMER | slide-8 Transfusion in Critical Illness or Bleeding Pooled Meta-Analysis in 2364 Patients MACE Salpeter, et al AJM 2014 ©2013 MFMER | slide-9 Transfusion in Critical Illness or Bleeding Pooled Meta-Analysis in 2364 Patients In-Hospital Mortality Restrictive transfusion trigger of Hgb 100 different associated factors • System intervention and adherence to evidence-based practices may improve compliance and outcome ©2013 MFMER | slide-27 Mayo Clinic Rochester, MN CAM ON barsness.gregory@mayo.edu CP1124540-1 ©2013 MFMER | slide-28