More than a decade ago, the Institute of Medicine challenged medical care providers and systems to improve healthcare delivery across six essential areas: safety, effectiveness, efficiency, timeliness, equity, and patient-centeredness (Figure 1-1) in Crossing the Quality Chiasm: A New Health System for the 21st Century. Antecedent to the establishment of these goals, the same body recognized in To Err is Human: Building a Safer Health System that up to 100,000 patients in hospitals die needlessly each year from avoidable medical errors. Despite the extensive resources devoted by national and local governments, health systems, and individuals to improvements in patient safety and error reduction, disappointingly, studies demonstrate that since these seminal publications, we have not achieved enough. Medical errors continue to occur at an alarming rate; and as the definition of unacceptable hospital-based events broadens to include morbidities, such as hospital-acquired infections, pressure ulcers, and preventable delays in care, the disparity between the goals and reality of US health care is only more apparent.

Figure 1-1

Institute of Medicine’s six domains of quality improvement.

Most recently, the paradigm for healthcare improvement has shifted to not only incorporate the impact of quality improvement on the individual patient, but on the population at large. With its focus on reducing the overall costs of care, optimizing the collective health of target populations, in addition to improving the individual patient care experience, the Institute for Healthcare Improvement’s (IHI) “Triple Aim Initiative” seeks to unify strategies for patient safety and quality improvement within the context of a more integrated and collaborative care delivery model than previously witnessed (Figure 1-2). The IHI identified several principal elements to help guide achievement of these aims, including the reorganization of primary care services, an emphasis on population-based wellness goals, and the development of cost-reduction strategies. Finally, although the Triple Aim Initiative still prioritizes the six aims of improvement for the individual care experience as set forth in Crossing the Quality Chiasm, it goes further to integrate the concepts of better patient care, improved community health, and lower cost (Table 1-1).

Figure 1-2

Schematic of the IHI Triple Aim Initiative. By improving the health of individuals and families, the overall wellness of a population improves and thus the costs to the system can be dramatically reduced.

Table 1-1The Definitions of the Institute of Medicine Domains

As medical technologies and clinical practice evolve, it is imperative that they be considered in the framework of the patient experience, population health, and cost reduction (Figure 1-3) as defined by the Triple Aim Initiative. Only in so doing, can we, the consumers of health, be assured that our best interests remain at the forefront of such innovation. A striking example of one medical tool that has broad implications for each of these elements is bedside critical care ultrasonography. A rapid, noninvasive, high-yield radiographic modality, ultrasound is almost universally the gold standard diagnostic tool for the evaluation of obstetric and gynecologic abnormalities. Additionally, it has garnered widespread acceptance for guidance of regional anesthesia, invasive catheter placement, and as a first-line method of evaluating neonatal intracranial pathology. Given its unique features—portable, noninvasive, radiation-sparing, and dynamic—ultrasound is a desirable tool for optimizing the individual patient care experience, reducing healthcare costs, and improving population well-being. Particularly for critically ill populations for whom timely, minimal-risk, and high-yield diagnostics are essential, bedside ultrasound may be a transformative healthcare tool. In order to facilitate understanding of the value of critical care ultrasonography within the paradigm of the three aims, it is instructive to first overview the current practical application of ultrasound in the intensive care unit (ICU).

Figure 1-3

Key elements of quality in the triple aim model.

Practical Application of Ultrasound in the ICU


Current literature suggests that the use of critical care ultrasound has enhanced technical proficiency among critical care providers; has improved procedural outcomes and in some instances, facilitated more timely diagnosis of medical problems than traditional radiographic methods. Furthermore, experiential reflection over time on the inherent advantages and pitfalls of bedside ultrasound has facilitated more judicious and efficacious application of this technology. Published guidelines now exist to define the ideal use of bedside ultrasound in various diagnostic and treatment algorithms. The enhanced safety profile of ultrasonography, in comparison to invasive or radiation-emitting techniques, has made it an attractive alternative across a broad range of clinical scenarios, including pulmonary, cardiac, and traumatic conditions.

Overview of Current Practice

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