Effects of organizational change in the medical intensive care unit of a teaching hospital - A comparison of 'open' and 'closed' formats
Effects of organizational change in the medical intensive care unit of a teaching hospital - A comparison of 'open' and 'closed' formats
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DOI：
10.1001/jama.276.4.322
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发表时间：
1996-07-24
影响因子：
120.7
通讯作者：
Hall, J
中科院分区：
文献类型：
--
作者：
Carson, SS;Stocking, C;Hall, J
客观。-比较从开放式到封闭式重症监护病房（ICU）格式的变化对临床结局、资源利用、教学和护理质量的影响。前瞻性队列研究;前瞻性经济学评价。一所大学三级护理中心的医学ICU。对于开放式ICU，初级入院医生通过咨询重症监护专家的意见指导患者的护理。对于封闭的ICU，重症监护专家直接病人护理。124例开放式ICU格式下入院的患者和121例转为封闭式ICU格式后入院的患者的对比性样本。排除再入院。主要结果指标。比较住院死亡率与急性生理学和慢性健康评估II（APACHE II）系统预测的死亡率;机械通气的持续时间;住院时间;放射科、实验室和药房的患者费用;血管导管的使用;正式教学查房的中断次数;以及患者、家属、医生和护士对护理质量和ICU功能的看法。开放式ICU的平均+/-SD APACHE II评分为15.4+/-8.3，封闭式ICU为20.6+/-8.6（P= 0.001）。在封闭的ICU中，实际死亡率（31.4%）与预测死亡率（40.1%）的比值为0.78。在开放ICU中，实际死亡率（22.6%）与预期死亡率（25.2%）的比值为0.90。开放式ICU中幸存者的平均住院时间为3.9天，封闭式ICU中幸存者的平均住院时间为3.7天（P= 0.79）。放射科、实验室或药房资源的患者费用在不同时期之间没有显着差异。与开放式ICU相比，护士更有可能表示，他们对封闭式ICU中主要负责患者护理的医生的临床判断非常有信心（41% vs 7%; P
Objective.-To compare the effects of change from an open to a closed intensive care unit (ICU) format on clinical outcomes, resource utilization, teaching, and perceptions regarding quality of care.Design.-Prospective cohort study; prospective economic evaluation.Setting.-Medical ICU at a university-based tertiary care center. For the open ICU, primary admitting physicians direct care of patients with input from critical care specialists via consultation. For the closed ICU, critical care specialists direct patient care.Patients.-Consecutive samples of 124 patients admitted under an open ICU format and 121 patients admitted after changing to a closed ICU format. Readmissions were excluded.Main Outcome Measures.-Comparison of hospital mortality with mortality predicted by the Acute Physiology and Chronic Health Evaluation II (APACHE II) system; duration of mechanical ventilation; length of stay; patient charges for radiology, laboratory, and pharmacy departments; vascular catheter use; number of interruptions of formal teaching rounds; and perceptions of patients, families, physicians, and nurses regarding quality of care and ICU function.Results.-Mean+/-SD APACHE II scores were 15.4+/-8.3 in the open ICU and 20.6+/-8.6 in the closed ICU (P=.001). In the closed ICU, the ratio of actual mortality (31.4%) to predicted mortality (40.1%) was 0.78. In the open ICU, the ratio of actual mortality (22.6%) to predicted mortality (25.2%) was 0.90. Mean length of stay for survivors in the open ICU was 3.9 days, and mean length of stay for survivors in the closed ICU was 3.7 days (P=.79). There were no significant differences between periods in patient charges for radiology, laboratory, or pharmacy resources. Nurses were more likely to say that they were very confident in the clinical judgment of the physician primarily responsible for patient care in the closed ICU compared with the open ICU (41 % vs 7%; P