(Not) Everybody Is Working for the Weekend.
(Not) Everybody Is Working for the Weekend.
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（不是）每个人都在周末工作。
DOI：
10.1097/ccm.0000000000002881
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发表时间：
2018
影响因子：
8.8
通讯作者：
Hyzy,RobertC
中科院分区：
文献类型：
--
作者：
Wheeler,DavidS;Hyzy,RobertC
多年来，ICU重症监护人员的配备强度一直被认为是ICU预后的重要影响因素(1)。在美国，Leapfrog集团等组织对认证的要求，具体规定了白天重症监护人员的存在，这可能与应对迅速增长的重症监护患者群体所需的重症监护人员和护理模式的假定短缺不一致（2-4）。虽然重症监护室在周末可能会配备高技能的护士和呼吸治疗师，但在那段时间，重症监护医生的可用性减少，导致了对护理服务和结果的担忧。自20世纪70年代以来，有关周末医疗服务欠佳的流行病学线索就已经出现。Rogot等人(5)公布了充血性心脏病、中风和流感死亡率的每日变化，这些变化清楚地表明，与工作日相比，周末的死亡率更高，即所谓的“周末效应”。从最初的观察性研究中，尚不清楚死亡率的增加是由于疾病患病率、严重程度的增加还是由于护理不佳。这个问题在Bell和Redelmeier(6)的一项研究中得到了解决，该研究评估了1988年至1997年间300多万住院患者的队列。作者证明，如腹主动脉瘤破裂、急性会厌和肺栓塞等情况下，患者在周末入院时死亡率增加。此外，在导致住院死亡率最高的100种情况中，有23种表现出周末死亡率较高的惊人模式。自2001年以来，超过17项队列研究集中在非工作时间ICU住院是否与预后恶化有关的问题上。这些研究的差异很大，研究之间的差异归因于不同的轮班制度、重症医师覆盖范围、医患比例，甚至“非工作时间”的定义。此前，Cavallazzi等人(7)对10项队列研究进行了荟萃分析，共纳入135,000多名患者。与预期相反，夜间住院与预后恶化之间没有关联；然而，周末入院与死亡率之间存在关联。后一项发现受到了质疑，因为它主要是由分析中包含的10项研究中的一项研究的结果驱动的。Cavallazzi等人(7)的系统评价的另一个缺点是没有考虑周末死亡率增加的潜在原因。
The intensity of intensivist staffing in the ICU has been known to be an important influence on ICU outcomes for many years (1). In the United States, requirements for certification by organizations such as the Leapfrog Group, specifying intensivist presence during daytime hours, are potentially at odds with a putative shortage of intensivists and models of care required to address the needs of a burgeoning critical care patient population (2–4). Although the ICU may be staffed on weekends with highly skilled nurses and respiratory therapists, lessened intensivist availability during that time has led to concerns about care delivery and outcomes. Epidemiologic clues about suboptimal medical care on the weekends have been present since the 1970s. Rogot et al (5) published the daily variations in congestive heart disease, stroke and influenza mortality which clearly demonstrated higher rates of death on weekends compared with weekdays, the socalled “weekend effect.” It was unclear from this initial observational study whether increased mortality was the result of increased disease prevalence, severity, or suboptimal care. That question was addressed in a study by Bell and Redelmeier (6) which evaluated a cohort of over 3 million hospital admissions from 1988 to 1997. The authors demonstrated that conditions such as ruptured abdominal aortic aneurysm, acute epiglottis, and pulmonary embolism had an increased mortality when a patient was admitted over the weekend. Furthermore, of the top 100 conditions that resulted in hospital mortality, 23 demonstrated this alarming pattern of higher weekend mortality.Since 2001, over 17 cohort studies have focused on the question of whether out-of-hours ICU admission is associated without worsened outcomes. These studies have been highly variable, and discrepancies between studies have been attributed to different work shift schemes, intensivist coverage, physician-to-patient ratio, and even definition of “out-of-hours.” Previously, the most complete analysis was done by Cavallazzi et al (7) in a meta-analysis of 10 cohort studies consisting of a total of over 135,000 patients. Contrary to expectations, there was no association between night admission and worsened outcomes; however, an association between weekend admissions and mortality was found. This latter finding was met with skepticism as it was mainly driven by results from only one of the 10 studies included in the analysis. Another shortcoming of the systematic review by Cavallazzi et al (7) was the lack of consideration of potential causes for the increased weekend mortality.