Unintended consequences, such as limited ability to think beyond algorithms, may exist when protocols are used extensively. In the September issue of the Journal of American Medical Association, Prasad et al studied the relationship between critical care training under high- and low-intensity institutional mechanical ventilation protocols and subsequent knowledge about ventilator management.

Results showed 86% of all respondents had protocols for ventilation liberation, 73% had protocols for sedation management and 60% had protocols for lung-protective strategies. The overall pass rate was 91%; there was no difference in the mean scores on the mechanical ventilation questions between the high- and low-intensity groups (high- intensity mean score, 497; 95% confidence interval [CI], 486-507; low-intensity mean score, 497; 95% CI 485-509).

These results suggest that trainees from hospitals with high- intensity ventilation protocols do not demonstrate knowledge deficits regarding mechanical ventilation as compared to trainees from hospitals with low-intensity protocols.

Potential limitations to this work include the use of examination questions to test knowledge exclusively about mechanical ventilation and the fact that the study population consisted of examinees trained in internal medicine, not surgery, anesthesiology or emergency medicine. Nevertheless, this study has important implications for physician-educators, because the unintended consequences of protocols on education have not been evaluated broadly. Clinical protocols, which are designed to enhance and standardize patient care, may have an impact on medical education, especially in an era where work-hours are limited and care has become compartmentalized.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.