Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit.
Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit.
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DOI：
10.1097/ccm.0b013e3181ffdd2f
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发表时间：
2011-02
影响因子：
8.8
通讯作者：
Iwashyna TJ
中科院分区：
文献类型：
--
作者：
Netzer G;Liu X;Shanholtz C;Harris A;Verceles A;Iwashyna TJ
评估多成分干预措施（特别是增加人员）是否可以在已经高强度、符合 Leapfrog 标准的医疗重症监护病房中降低患者死亡率。回顾性、观察性研究。三级医疗、学术医疗中心的医疗重症监护室。将2004年4月19日至2006年4月18日（组织变革前）期间收治的总共1,263名患者与2006年9月5日至2008年9月4日期间收治的2,424名患者进行了比较。多方面干预措施包括从10个床位的医疗重症监护病房搬迁到拥有更大病房的29个床位的医疗重症监护病房，在医院中启动24小时重症监护专家覆盖。医疗重症监护病房，增加呼吸治疗师与患者的比例，以及在多学科团队中增加一名临床药剂师。测量是根据重症监护病房和医院内的死亡率进行的。干预后，通过查尔森评分衡量的患者合并症没有变化（2.7 ± 2.7 vs. 2.8 ± 2.6，p = .62），通过病例混合指数衡量的疾病严重程度也没有变化（3.0 ± 3.7 vs. 3.1 ± 3.8，p = .69）。未经调整的医疗重症监护病房死亡率从 18.4% 下降至 14.9% (p = .006)，院内死亡率也是如此（从 25.8% 下降至 21.7%，p = .005）。医疗重症监护病房死亡率的降低与对多种可能的混杂因素进行调整后的多变量回归一致（比值比 = 0.74，95% 置信区间：0.61–0.91，p = .003），医院死亡率的降低也是一致的（比值比 = 0.74，95% 置信区间：0.62–0.88，p = .001）。在机械通气患者中，中位 28 天不使用呼吸机的天数有所增加（21 天，四分位间距 0 –25 vs. 22，四分位间距 0 –26，p = .04）。干预期间，住院天数中位数有所增加（2.4，四分位距 1.1-5.2 vs. 2.7，四分位距 1.3-5.9），p = .009），但住院天数没有增加（8.3，四分位距 4.1-17.0 vs. 8.2，四分位距 4.0 –16.8；p = .851）。干预后芬太尼和劳拉西泮的平均每日剂量减少。医疗重症监护病房服务的多方面重组与医疗重症监护病房患者死亡率的显着降低以及无呼吸机天数的增加有关。临床重要结果的实质性和持续变化可以通过组织变革获得。
To evaluate whether a multicomponent intervention, particularly increasing staff, can achieve reductions in patient mortality in an already high-intensity, Leapfrog-compliant medical intensive care unit. Retrospective, observational study. Medical intensive care unit of a tertiary care, academic medical center. A total of 1,263 patients admitted between April 19, 2004 and April 18, 2006 (before the organizational change) were compared with 2,424 patients admitted between September 5, 2006 and September 4, 2008. A multicomponent intervention including the physical move from a 10-bed to a 29-bed medical intensive care unit with larger patient rooms, the initiation of 24-hr critical care specialist coverage in the medical intensive care unit, an increase in the respiratory therapist:patient ratio, and the addition of a clinical pharmacist to the multidisciplinary team. Measurements were made based on mortality in the intensive care unit and in-hospital. Patient comorbidity as measured by the Charlson score did not change after the intervention (2.7 ± 2.7 vs. 2.8 ± 2.6, p = .62), nor did the acuity of illness as measured by the case mix index (3.0 ± 3.7 vs. 3.1 ± 3.8, p = .69). The unadjusted medical intensive care unit mortality decreased from 18.4% to 14.9% (p = .006), as did in-hospital mortality (from 25.8% to 21.7%, p = .005). The reduction in medical intensive care unit mortality was consistent in the multivariable regression with adjustment for multiple possible confounders (odds ratio = 0.74, 95% confidence interval: 0.61– 0.91, p = .003), as was the reduction in hospital mortality (odds ratio = 0.74, 95% confidence interval: 0.62– 0.88, p = .001). In mechanically ventilated patients, there was an increase in median 28-day ventilator-free days (21, interquartile range 0 –25 vs. 22, interquartile range 0 –26, p = .04). An increase in median medical intensive care unit (2.4, interquartile range 1.1–5.2 vs. 2.7, interquartile range 1.3–5.9), p = .009) but not hospital (8.3, interquartile range 4.1–17.0 vs. 8.2, interquartile range 4.0 –16.8; p = .851) length of stay in days occurred with the intervention. The mean daily dosing of fentanyl and lorazepam decreased after the intervention. A multicomponent reorganization of medical intensive care unit services was associated with important reductions in mortality for medical intensive care unit patients, as well as an increased number of ventilator-free days. Substantial and sustained changes in clinically important outcomes may be obtained from organizational changes.