Association between Adherence to Recommended Care and Outcomes for Adult Survivors of Sepsis
Association between Adherence to Recommended Care and Outcomes for Adult Survivors of Sepsis
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DOI：
10.1513/annalsats.201907-514oc
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发表时间：
2020-01-01
影响因子：
8.3
通讯作者：
Kowalkowski, Marc A.
中科院分区：
文献类型：
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作者：
Taylor, Stephanie Parks;Chou, Shih-Hsiung;Kowalkowski, Marc A.
基本原理：脓毒症后护理建议针对脓毒症幸存者在以下要素中经历的特定缺陷：优化药物治疗，筛查功能障碍，监测健康恶化的常见和可预防原因，以及考虑姑息治疗。然而，关于这些元素在临床practice.Objectives中的应用的数据很少：为了量化脓毒症患者入院后出院的脓毒症后护理的提供，并评估接受脓毒症后护理元素与降低死亡率和90天内再入院之间的关联。我们对因败血症入院后存活出院的随机样本患者进行了回顾性病历分析（根据国际疾病分类第10版出院代码确定）。我们使用结构化图表摘要来确定是否在出院后90天内根据专家建议提供了脓毒症后护理的四个要素。我们使用多变量逻辑回归来评估接受护理要素与90天再入院率和死亡率之间的相关性，调整了年龄、合并症、住院时间和出院处置。在189名败血症幸存者中，117名（62%）进行了药物优化，123名（65%）进行了功能或精神健康障碍筛查，86人（46%）接受了健康恶化的常见和可预防原因的监测，110人（58%）记录了护理调整过程（即，评估姑息治疗或治疗目标）。只有20人（11%）在90天内接受了所有四种护理要素。出院后90天内，66例（35%）患者再次入院，33例（17%）患者死亡（再次入院或死亡的患者总数，n = 82）。接收两个（比值比[0.26; 95%置信区间[95% CI]，0.100.69）或以上（3个OR，0.28; 95% CI，0.11 - 0.72; 4个OR，0.12; 95%CI，0.03 - 050）护理要素与90天再入院或90天死亡率的几率较低相比，零或一个要素记录。药物优化（无用药错误vs. 1个或多个错误; OR，0.44; 95% CI，0.21 - 0.92），记录功能或心理健康评估（身体功能+吞咽/心理健康评估vs.无评估; OR，0.14; 95% CI，0.05 - 0.40），以及记录的护理或姑息治疗筛选目标（OR，0.52; 95%CI，0.25 - 1.05;无统计学显著性）与90天再入院或90天死亡率较低的几率相关。结论：在这项回顾性队列研究中，从一个单一的卫生系统的数据，我们发现变量交付的建议败血症后的护理元素，与败血症住院后的发病率和死亡率降低。实施策略，以有效地克服障碍，采用建议的脓毒症后护理可能有助于改善脓毒症幸存者的结果。
Rationale: Postsepsis care recommendations target specific deficits experienced by sepsis survivors in elements such as optimization of medications, screening for functional impairments, monitoring for common and preventable causes of health deterioration, and consideration of palliative care. However, few data are available regarding the application of these elements in clinical practice.Objectives: To quantify the delivery of postsepsis care for patients discharged after hospital admission for sepsis and evaluate the association between receipt of postsepsis care elements and reduced mortality and hospital readmission within 90 days.Methods: We conducted a retrospective chart review of a random sample of patients who were discharged alive after an admission for sepsis (identified from International Classification of Diseases, 10th Revision discharge codes) at 10 hospitals during 2017. We used a structured chart abstraction to determine whether four elements of postsepsis care were provided within 90 days of hospital discharge, per expert recommendations. We used multivariable logistic regression to evaluate the association between receipt of care elements and 90-day hospital readmission and mortality, adjusted for age, comorbidity, length of stay, and discharge disposition.Results: Among 189 sepsis survivors, 117 (62%) had medications optimized, 123 (65%) had screening for functional or mental health impairments, 86 (46%) were monitored for common and preventable causes of health deterioration, and 110 (58%) had care alignment processes documented (i.e., assessed for palliative care or goals of care). Only 20 (11%) received all four care elements within 90 days. Within 90 days of discharge, 66 (35%) patients were readmitted and 33 (17%) died (total patients readmitted or died, n = 82). Receipt of two (odds ratio [On 0.26; 95% confidence interval [95% CI], 0.100.69) or more (three OR, 0.28; 95% CI, 0.11-0.72; four OR, 0.12; 95% CI, 0.03-050) care elements was associated with lower odds of 90-day readmission or 90-day mortality compared with zero or one element documented. Optimization of medications (no medication errors vs. one or more errors; OR, 0.44; 95% CI, 0.21-0.92), documented functional or mental health assessments (physical function plus swallowing/mental health assessments vs. no assessments; OR, 0.14; 95% CI, 0.05-0.40), and documented goals of care or palliative care screening (OR, 0.52; 95% CI, 0.25-1.05; not statistically significant) were associated with lower odds of 90-day readmission or 90-day mortality.Conclusions: In this retrospective cohort study of data from a single health system, we found variable delivery of recommended postsepsis care elements that were associated with reduced morbidity and mortality after hospitalization for sepsis. Implementation strategies to efficiently overcome barriers to adopting recommended postsepsis care may help improve outcomes for sepsis survivors.