减少错误—增加临床试验的严谨性及临床实践的一致性ppt课件

1、Alan H. Morris, M.D.减少错误 添加临床实验的严谨性及临床实际的一致性“人不能好于他所运用的工具中国心衰论坛大连, 中国，2021年8月20-22日好的科学研讨结果应该可以复制(这需求一个详细的可反复的方法)临床任务和科研方法是不可复制的(需求更多变的临床判别)自1987年来，我们不断运用床旁计算机规程作为一个可复制的临床方法随后的3个图表是成人和儿科ICU及常规临床任务中血糖控制的结果血糖 (mg/dl)8 6 4 20 04080 120 160 200 240 280 320床旁计算机规程床旁纸质规程单纯指南P0.0001目的范围 % 血糖丈量曲线下面积 = 100%血

2、糖 (mg/dl)8 6 4 20 04080 120 160 200 240 280 320USA西部USA东南部USA东北部新加坡P=0.18血糖计算机规程% 血糖丈量目的范围 我们想与中国的研讨者协作这项研讨将把计算机规程运用到研讨者的临床任务中研讨者将作为出版物的合著者 临床任务中不用要的偏向和错误 计算机规程将经过可反复的方法，协助临床医生做出一致的，循证的决策% 165个诊所,15,381名门诊心衰患者接受了适当的根据指南的治疗最大值90%中数10%最小值阐明:临床研讨结果的范围% 临床任务中不用要的偏向和错误 计算机规程将经过可反复的方法，协助临床医生做出一致的，循证的决策 指南

3、: “政策规那么或原那么的系统声明- 通知去哪，而不是怎样去。 规程: “准确而详细的方案.医学 .问题和/或. 治疗 通知怎样去 。 (一个十清楚确的规程有充分的细节以便于不同的临床医生对同样的病人特异性的决策- 这就是一个可反复的临床决策方法) 10王皓在王皓在竞赛竞赛中中马琳在竞赛中马琳在竞赛中指南“博得这个球不十清楚确的参数“打左角十清楚确的规程“等待回球高时，左旋用力击球， 转到对手的左侧,落在间隔左侧台角1英寸内。 目的: 血压140/90 mmHg，伴最少的或没有副作用 。 假设3个月后血压仍未达标，缓慢添加剂量。高血压的控制指南什么是最少的副作用？每周晕倒一次是最少吗？什么是缓

4、慢？每天，每周，每月还是每3个月？不够明确的指南样本不够明确的指南样本将O2降低10%，从90%到80%坚持潮气量为 540ml频率从22次/分添加到25次/分15:40采动脉血气机械通气十清楚确的建议：可反复的临床决策方法规范化的决策 规范化的任务 每个引荐的参数根据病人的资料至少产生一种规范化决策每个病人有独特的数据患者的治疗 = (随时间推移，由特定患者的数据产生的规范决策)。因此计算机规程是有顺应才干的(它根据患者的变化而变化)下面有3个计算机界面样本:规范化的决策 规范化的任务机械通气参数计算机界面样本静脉液体 / 血流动力学参数计算机界面样本血糖/胰岛素记录：成人和儿童计算机界面样

5、本我们经过这个血糖计算机规程将研讨的结果运用于临床实际血糖 (mg/dl)8 6 4 20 04080 120 160 200 240 280 320ICU研讨临床实际(13 个成人ICU)目的范围 % 血糖丈量 好的科学需求可反复性方法 临床任务中不用要的偏向和错误。 计算机规程将经过可反复的方法，协助临床医生做出一致的，循证的决策。英文版23Alan H. Morris, M.D.Reducing error - Increasing the scientific rigor of clinical experiments and the consistency of clinical c

6、are“Man is only as good as the tools he uses.GoetheChina Heart Failure SymposiumDalian, Peoples Republic of China 20-22August0924Good science requires replication of study results (this requires a detailed reproducible method)Clinical care and research methods are not reproducible (require much vari

7、able clinician judgment).We have used bedside Computer Protocols to provide a reproducible clinical method since 1987The following 3 graphs are results for Blood Glucose control in adult and pediatric ICUs and in usual clinical careBlood Glucose (mg/dl)8 6 4 20 04080 120 160 200 240 280 320Bedside C

8、omputer ProtocolBedside Paper ProtocolSimple GuidelineP0.0001TargetRange % Blood GlucoseMeasurementsArea under curve = 100%Blood Glucose (mg/dl)8 6 4 20 04080 120 160 200 240 280 320Western USASoutheast USANortheast USASingaporeP=0.18TargetRange Blood Glucose Computer Protocol% Blood GlucoseMeasurem

9、ents28We seek research collaboration with investigators in the Peoples Republic of ChinaThis research will introduce computer protocols for care in the investigators clinical units.The investigators will be coauthors of publications.29 Unnecessary variation and error exists in medical care. Computer

10、 protocols help clinicians deliver consistent, evidence-based care with a reproducible method.% of 15,381 Heart Failure Outpatients ReceivingAppropriate Guideline-Based Treatment In 165 clinicsMaximum90% of clinicsMedian10% of clinicsMinimumLegend:Range of results bystudy clinic%31 Unnecessary varia

11、tion and error exists in medical care Computer protocols help clinicians deliver consistent, evidence-based care with a reproducible method.32 Guideline: “A systematic statement of policy rules or principles- tells where to go, but not how to get there. Protocol: “Precise and detailed plans for .a m

12、edical .problem and/or. therapy. - tells how to get there. (An adequately explicit protocol has enough detail so different clinicians make the same patient-specific decision - it is a reproducible clinical decision method) 3233王皓在王皓在竞赛竞赛中中马琳在竞赛中马琳在竞赛中34Guideline“Win the pointInadequately explicit pr

13、otocol“Hit the left cornerAdequately explicit protocol“Wait for a high return and hit the ball hard with a left spin, curving to the opponents left, to land within 1 inch of the left corner of the table. Goal: Blood Pressure140/90 mmHg with minimal or no adverse effects. If after 3 months, BP not at

14、 Goal, increase dose slowly.Guideline for Controlling High Blood Pressurewhat are minimal adverse effects? Is one episode of fainting a week minimal?what is slowly? Is it an increase daily, weekly, monthly, every 3 months?Inadequately explicit guideline example(不够明确)Reduce O2 by 10% from 90 to 80%Ma

15、intain Tidal Volume at 540mlIncrease Rate from 22 to 25/minuteSample Arterial Blood at 15:40 hoursAdequately Explicit recommendations for Mechanical Ventilation: A Repro-ducible Clinical-Decision MethodStandardized Decisions Standardized Care37 Each protocol recommendation produces at least one Stan

16、dardized Decision from patient data.Each patient provides unique data.Patient Care = (Standardized Decisions from unique patient data over time). The computer protocol is therefore adaptive (it responds to changes in the patient).3 computer interface examples follow: Standardized Decisions Standardi

17、zed Care38Mechanical Ventilation ProtocolComputer Interface Example39IV Fluid / Hemodynamic ProtocolComputerInterface Example血糖/胰岛素记录：成人和儿童ComputerInterface ExampleWe used this Blood Glucose Computer Protocol to translate our research results into Clinical PracticeBlood Glucose (mg/dl)8 6 4 20 04080 120 160 200 240 280 320Research ICUClin