In patients with acute lung injury (ALI) and ARDS, conventional mechanical ventilation (CV) may cause additional lung injury from overdistention of the lung during inspiration, repeated opening and closing of small bronchioles and alveoli, or from excessive stress at the margins between aerated and atelectatic lung regions. Increasing evidence suggests that smaller tidal volumes (VTs) and higher end-expiratory lung volumes (EELVs) may be protective from these forms of ventilator-associated lung injury and may improve outcomes from ALI/ARDS. High-frequency ventilation (HFV)-based ventilatory strategies offer two potential advantages over CV for patients with ALI/ARDS. First, HFV uses very small VTs, allowing higher EELVs with less overdistention than is possible with CV. Second, despite the small VTs, high respiratory rates during HFV allow the maintenance of normal or near-normal PaCO2 levels. In this review, the use of HFV as a lung protective strategy for patients with ALI/ARDS is discussed.

To improve the effectiveness of evidence-based clinical practice guidelines (CPGs), four other components of implementation are necessary. Together, they impressively optimize the process and outcomes of health care, and reduce undesirable variation of care. Aside from CPGs, the four components help make up a successful, long-term, facility-wide, comprehensive disease-management program. First, executive clinical and administrative leaders need to create the expectation and reveal hands-on commitment. Second, work-simplification tools are needed to accomplish the tasks more effectively and to encourage a path of least resistance. Third, useful, accurate metrics are needed to provide feedback for patients and health-care providers who need the most assistance. These metrics must be easily obtained, disseminated in near-real time, patient-specific, anonymous to others, and penalty free. Fourth, and most important, with nonmonetary compensation, this review addresses the question, "What's in it for all the passionate people who assist in the delivery of health care?"

Clinical audits and practice profiling have become popular tools in the attempt to change physician behavior to improve quality of care. Unfortunately, the growing need for information on quality of care has often outpaced the development of standard, valid, and reliable approaches to using these tools. The studies of performance measurement published in the literature to date demonstrate varying impact on ability to improve clinical care; few are randomized controlled trials. While performance measurement has become a common practice, the science surrounding this field is still in its early stages of development; while it seems promising, it should be viewed as largely experimental.

Computer decision support systems are computer applications designed to aid clinicians in making diagnostic and therapeutic decisions in patient care. They can simplify access to data needed to make decisions, provide reminders and prompts at the time of a patient encounter, assist in establishing a diagnosis and in entering appropriate orders, and alert clinicians when new patterns in patient data are recognized. Decision support systems that present patient-specific recommendations in a form that can save clinicians time have been shown to be highly effective, sustainable tools for changing clinician behavior. Designing and implementing such systems is challenging because of the computing infrastructure required, the need for patient data in a machine-processible form, and the changes to existing workflow that may result. Despite these difficulties, there is substantial evidence from trials in a wide range of clinical settings that computer decision support systems help clinicians do a better job caring for patients. As computer-based records and order-entry systems become more common, automated decision support systems will be used more broadly.

Evidence-based guidelines hold considerable promise for continued improvement of health-care delivery. However, the availability of clinical practice guidelines does not automatically lead to changes in practice patterns. Using a "push-pull-capacity" model, this article describes strategies to improve guideline implementation for three types of organizations: national organizations, insurer and health-care organizations, and health-care purchasers. Push strategies focus on the guideline development process and include rigorous review and meta-analysis of peer-reviewed research, and use of multidisciplinary expert teams, subjecting guidelines to peer review and comment and using measurable clinical outcomes to define guidelines. PULL: strategies focus on creating a demand for guideline implementation and include professional organization endorsement, quality measures based on guideline-related outcomes, and guideline-based performance objectives in purchaser contracts and physician compensation agreements. Capacity strategies focus on systems that facilitate guideline implementation. Example strategies are providing benefit coverage and reimbursement for guideline-based treatment protocols, and implementing clinical information systems for population-based tracking, outcomes monitoring, and benchmarking feedback.

Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education.