Grand Rounds Report: Following Protocols or Individualized Care in Intensive Care Units?

by Academy of Clinical Excellence on September 17, 2010

Yesterday, I had the opportunity to present Medical Grand Rounds at Johns Hopkins Bayview. After discussing a patient who was admitted with to the medical intensive care unit with very low systolic blood pressure (who was later discovered to have low blood pressures when he is well), I presented data and perspective related to the following question: When should doctors follow standard treatment protocols and when is it better to override protocols and deliver individualized care?

The structure of an intensive care unit may play an important role in providing excellent care. A number of studies have shown that the physician and nursing staffing of an intensive care unit, as well as the presence of clinical protocols, designed to ensure that patients receive proven therapies, can affect both the care of patients as well as clinical outcomes. The real challenge for clinicians is in determining when a patient should or should not receive care according to a protocol or care pathway. There are clearly patients who benefit from care driven by protocols or guidelines; in fact many or most patients would fit in this category. However, some patients may not "fit" the category of patients who might benefit from the standardized care present in a protocol. For example, some patients may have additional diseases, specialized circumstances, or perhaps even a different genetic marker that might make them less likely to respond to the therapy encoded in the protocol.

The clinically excellent physician relies on knowledge, evidence, experience, judgment to determine which patients might not benefit from receiving the protocol, and is then willing to override the protocol.

Jonathan Sevransky, MD, MPH
Division of Pulmonary & Critical Care Medicine
Johns Hopkins Bayview Medical Center

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