Although its roots date back to the early decades of the 20th century, critical care medicine did not emerge as a specialty in medicine until the 1970 s. Over the last 30 years or so, the field of critical care medicine has grown tremendously and there is now a solid body of scientific information that forms the foundation for the practice of critical care medicine. But, now as physicians and hospitals around the world focus to an ever greater extend on providing high quality care, the practice of critical care medicine will continue to grow in visibility and importance among clinicians and the general public as well.

This book seeks to identify the trends in critical care medicine that will form the basis for practice over the next ten years. Predicting the future is always risky. Nevertheless, the ideas articulated in this book are likely to serve as a road map for intensivists, hospital administrators and governmental leaders interested in healthcare, as they seek to improve the quality and efficiency of hospital-based services."

This book describes how the integrated approach offered by health services research can improve the quality of care provided to critically ill patients. By focusing on the needs of the patient, health services research links conventional scientific disciplines, systems research, education, and management, with the aim of translating developments in knowledge into sustained change in culture and practice. Intensive care has much to offer in this respect, as it can both benefit from and contribute to the collaborative methodology of health services research. Although the contributions are directed at critical care, the content is relevant to all health care disciplines, including health services administration.

Researchers from many disciplines, with both basic and clinical perspectives, came together in this volume to review and debate issues pertaining to the investigation and control of tissue oxygenation in acute medicine, as well as treatments to improve tissue oxygenation when abnormal. In this latter context, special emphasis is placed on understanding the effect of blood substitutes on the circulation and on the potential roles of this family of compounds in clinical medicine.

Measuring the quality of a complex service like critical care that combines the highest technology with the most intimate caring is a challenge. Recently, con sumers, clinicians, and payers have requested more formal assessments and comparisons of the quality and costs of medical care [2]. Donabedian [1] pro posed a framework for thinking about the quality of medical care that separates quality into three components: structure, process, and outcome. An instructive analogy for understanding this framework is to imagine a food critic evaluating the quality of a restaurant. The critic might comment on the decoration and lighting of the restaurant, how close the tables are to each other, the extent of the wine list and where the chef trained. These are all evaluations of the restaurant structure. In addition, the critic might comment on whether the service was courteous and timely - measures of process. Finally, the critic might comment on outcomes like customer satisfaction or food poisoning. Similarly, to a health care critic, structure is the physical and human resources used to deliver medi cal care. Processes are the actual treatments offered to patients. Finally, outcomes are what happens to patients, for example, mortality, quality of life, and satisfac tion with care (Table 1). There is a debate about which of these measurements is the most important measure of quality.