Journal of Critical Care 29 (2014) 477
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Editorial
August 2014: Critical Care in Transition
This issue of the Journal of Critical Care breaks new ground with the publication of the first of a planned 3 series set of invited articles titled Death by Neurologic Criteria 1968-2014: Changing Interpretations. Coordinated by Dr David Crippen, Professor in the Departments of Critical Care Medicine and Neurological Surgery, University of Pittsburgh Medical Center, the series promises to provide a comprehensive review of the literature detailing the past and present controversies and current practices surrounding the diagnosis and utilization of the diagnosis of death with specific reference to the topic of organ donation. The introduction and first 4 installments provide an intriguing view of the topic and set the stage for the manuscripts to follow. Recent high-profile cases in California and Texas should reinforce the necessity for an update in this important area, and I am grateful to Dr Crippen and all contributing authors to bring this topic to our attention. The open-access article this month is Myocardial depression in sepsis: from pathogenesis to clinical manifestations and treatment from E. Antonucci et al. (Italy and Belgium). This provides an interesting and important review of and insight into current management of a common problem. The remainder of the articles in the sepsis section provides updates on prognosis and patient management in a number of key areas. It is apparent that noninvasive ventilatory support and the use of high-flow nasal cannulas are increasingly used, and these interest areas are supplemented with articles dealing with a wide variety of topics dealing with new modes of ventilator support including “fuzzy logic” control as well as continuing studies with Acute Respiratory Distress Syndrome and the duration of endotracheal intubation. Paradoxical findings regarding the outcomes of obese patients with ARDS and prone positioning are also discussed. The invited editorial commentaries and the letters to the editor, which address issues related to neurally adjusted ventilatory assist, bear attention as does Turnbull, Parker and Needham's editorial “Supporting small steps toward big innovations: the importance of rigorous pilot studies in critical care”; it is difficult to know when pilot studies rise to the importance of accepted manuscripts, and this commentary provides important insight into the evaluation and selection process. Critical care medicine is a vibrant and innovative field with increasing requirements for innovation and change internationally. Irrespective of practice site, older patients with aggressive and complex diseases require attention in environments that show more resource disparity than in most other medical disciplines. No set of internationally applicable guidelines exist, and local and regional innovation, often described in this journal, are essential to future
http://dx.doi.org/10.1016/j.jcrc.2014.05.002 0883-9441/© 2014 Elsevier Inc. All rights reserved.
advances in the discipline. Resource constraints are ubiquitous, and irrespective of whether practices are located in either developing or developed nations, the defining factor for health care delivery is integration between government and private/philanthropic organizations. Societal and governmental philosophies of care dictate the manner in which available capital is allocated, and international comparisons on quality outcomes vs capital expenditures demonstrate a confused picture revealing that investment per se is incapable of ensuring quality or improved population health. The Journal of Critical Care encourages studies in health systems research that target these problems and ensure our readers the most appropriate venue in which to foster requisite change that is environment and situation specific. The United States faces different challenges because resource allocation across the population is inversely proportional to the likely productivity of the successfully discharged patient causing ethical dilemmas for government, citizen, and payer alike. Should the majority of health care dollars be spent in the terminal stags of life? Similar questions face ongoing implementation of health care legislation, and payment based on quality outcomes is increasingly recognized as a means of conserving resources; however, the only effective manner of containing cost is to remove it from the system. Maintenance of a health (wellness programs) and improved efficiency (decreased length of stay, lower readmission rates within 30 days of discharge, improving hospital/patient safety profiles) eliminate cost. A current focus is to standardize process and reduce system variability to recognize deviation from an anticipated care plan and permit earlier intervention. Demonstrably improved outcomes from such initiatives are increasingly apparent, and Early Recovery After Surgery programs have proved successful in the United Kingdom's National Health Service programs. It is apparent that this is not “cookbook” medicine; rather it is more aptly compared with carefully controlled clinical trials in which protocol development and application become the means to study not only future innovation but also to ensure anticipated outcome; this is a quality control philosophy in medicine that must approach and surpass industrial standards. The future of global health depends upon it. One of William Sibbald's defining themes for the Journal of Critical Care was a focus on health systems research. Nothing could be timelier, and I look forward to your contributions in this essential field.
Philip D. Lumb, MB, BS, MCCM Los Angeles, CA, USA E-mail address: [email protected]
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Editorial
August 2014: Critical Care in Transition
This issue of the Journal of Critical Care breaks new ground with the publication of the first of a planned 3 series set of invited articles titled Death by Neurologic Criteria 1968-2014: Changing Interpretations. Coordinated by Dr David Crippen, Professor in the Departments of Critical Care Medicine and Neurological Surgery, University of Pittsburgh Medical Center, the series promises to provide a comprehensive review of the literature detailing the past and present controversies and current practices surrounding the diagnosis and utilization of the diagnosis of death with specific reference to the topic of organ donation. The introduction and first 4 installments provide an intriguing view of the topic and set the stage for the manuscripts to follow. Recent high-profile cases in California and Texas should reinforce the necessity for an update in this important area, and I am grateful to Dr Crippen and all contributing authors to bring this topic to our attention. The open-access article this month is Myocardial depression in sepsis: from pathogenesis to clinical manifestations and treatment from E. Antonucci et al. (Italy and Belgium). This provides an interesting and important review of and insight into current management of a common problem. The remainder of the articles in the sepsis section provides updates on prognosis and patient management in a number of key areas. It is apparent that noninvasive ventilatory support and the use of high-flow nasal cannulas are increasingly used, and these interest areas are supplemented with articles dealing with a wide variety of topics dealing with new modes of ventilator support including “fuzzy logic” control as well as continuing studies with Acute Respiratory Distress Syndrome and the duration of endotracheal intubation. Paradoxical findings regarding the outcomes of obese patients with ARDS and prone positioning are also discussed. The invited editorial commentaries and the letters to the editor, which address issues related to neurally adjusted ventilatory assist, bear attention as does Turnbull, Parker and Needham's editorial “Supporting small steps toward big innovations: the importance of rigorous pilot studies in critical care”; it is difficult to know when pilot studies rise to the importance of accepted manuscripts, and this commentary provides important insight into the evaluation and selection process. Critical care medicine is a vibrant and innovative field with increasing requirements for innovation and change internationally. Irrespective of practice site, older patients with aggressive and complex diseases require attention in environments that show more resource disparity than in most other medical disciplines. No set of internationally applicable guidelines exist, and local and regional innovation, often described in this journal, are essential to future
http://dx.doi.org/10.1016/j.jcrc.2014.05.002 0883-9441/© 2014 Elsevier Inc. All rights reserved.
advances in the discipline. Resource constraints are ubiquitous, and irrespective of whether practices are located in either developing or developed nations, the defining factor for health care delivery is integration between government and private/philanthropic organizations. Societal and governmental philosophies of care dictate the manner in which available capital is allocated, and international comparisons on quality outcomes vs capital expenditures demonstrate a confused picture revealing that investment per se is incapable of ensuring quality or improved population health. The Journal of Critical Care encourages studies in health systems research that target these problems and ensure our readers the most appropriate venue in which to foster requisite change that is environment and situation specific. The United States faces different challenges because resource allocation across the population is inversely proportional to the likely productivity of the successfully discharged patient causing ethical dilemmas for government, citizen, and payer alike. Should the majority of health care dollars be spent in the terminal stags of life? Similar questions face ongoing implementation of health care legislation, and payment based on quality outcomes is increasingly recognized as a means of conserving resources; however, the only effective manner of containing cost is to remove it from the system. Maintenance of a health (wellness programs) and improved efficiency (decreased length of stay, lower readmission rates within 30 days of discharge, improving hospital/patient safety profiles) eliminate cost. A current focus is to standardize process and reduce system variability to recognize deviation from an anticipated care plan and permit earlier intervention. Demonstrably improved outcomes from such initiatives are increasingly apparent, and Early Recovery After Surgery programs have proved successful in the United Kingdom's National Health Service programs. It is apparent that this is not “cookbook” medicine; rather it is more aptly compared with carefully controlled clinical trials in which protocol development and application become the means to study not only future innovation but also to ensure anticipated outcome; this is a quality control philosophy in medicine that must approach and surpass industrial standards. The future of global health depends upon it. One of William Sibbald's defining themes for the Journal of Critical Care was a focus on health systems research. Nothing could be timelier, and I look forward to your contributions in this essential field.
Philip D. Lumb, MB, BS, MCCM Los Angeles, CA, USA E-mail address: [email protected]
