Designing a better "nest": applicable to preventing hospital exposures to risk factors for acute respiratory distress syndrome or just retrospective study design?
Designing a better "nest": applicable to preventing hospital exposures to risk factors for acute respiratory distress syndrome or just retrospective study design?
复制标题
设计更好的“巢”：适用于预防医院暴露于急性呼吸窘迫综合征的危险因素还是只是回顾性研究设计？
DOI：
10.1097/ccm.0b013e3182a11eab
复制
发表时间：
2014
影响因子：
8.8
通讯作者：
Levitt,Joseph
中科院分区：
文献类型：
--
作者：
Levitt,Joseph
尽管存在这些局限性，但这项研究的独特之处在于它能够使用经过充分验证的LIPS（2）来控制发生ARDS的基线风险。作者已经确定了可能显著增加ARDS发生率的重要且可能可预防的暴露。重要的是，作者还记录了10年研究期间与ARDS发病率下降相关的已确定风险因素的暴露率下降。进行这项研究的罗切斯特的马约诊所一直是标准化护理的领导者，以减少在ARDS途径上潜在的“二次打击”。在研究期间，实施了限制血液制品输注的特定方案（使用具有决策支持的计算机化订单输入）;限制机械通气患者的潮气量（包括呼吸治疗驱动的肺保护性通气方案，随后实施经验证的自动化电子监测和通知系统，记录减少暴露于较大潮气量的时间）（13）;败血症和肺炎订单集，计算机化订单输入和决策支持，以适当的抗生素输送;增加重症监护病房的重症监护人员;增加24小时现场重症监护人员（3）。与暴露于特定风险因素和ARDS之间的关联一样，暴露率下降与特定方案实施之间的时间关联并不能自动指定因果关系，并且取决于不同机构的不同系统和实践模式，特定方案在某些机构的有效性可能无法推广到其他中心。宾夕法尼亚大学医院最近的一项随机试验发现，增加夜间重症监护医生并没有提高医疗ICU的护理质量或效率，但在多大程度上可以将日间重症监护医生和协议护理过程的结果外推到其他中心尚不清楚（14）。尽管存在一些不确定性，现在有大量的经验证据表明，在住院期间暴露于几种潜在的可预防的危险因素会增加发展成ARDS的风险，并且实施常识性方案以提高护理标准化并降低暴露率可以显著降低ARDS的流行率。鉴于治疗ARDS的选择有限，共同努力进行预防似乎是一种高收益、低风险和可取的策略。与
Despite these limitations, this study is unique in that it was able to use the well-validated LIPS (2) to control for baseline risk of developing ARDS. The authors have identified important, and potentially preventable, exposures that may significantly increase rates of ARDS. Importantly, the authors also documented decreasing rates of exposures to the identified risk factors that correlated with falling rates of ARDS over the 10-year study period. The Mayo Clinic in Rochester, where the study was conducted, has been a leader in standardizing care to reduce rates of exposure to potential “secondary hits” on the pathway to ARDS. During the study period, specific protocols were implemented to restrict transfusion of blood products (using computerized order entry with decision support); limit tidal volumes for mechanically ventilated patients (including respiratory therapy driven lung-protective ventilation protocols followed by implementation of a validated automated electronic surveillance and notification system with documented reduced time of exposure to larger tidal volumes)(13); sepsis and pneumonia order sets with computerized order entry and decision support for appropriate antibiotic delivery; increased intensivist staffing in the medical ICU; and the addition of a 24-hour on-site intensivist (3). As with the association between exposure to specific risk factors and ARDS, the temporal association of the declining rates of exposures with implementation of specific protocols does not automatically assign causality and, depending on different systems and practice patterns across institutions, the effectiveness of specific protocols at certain institutions may not be generalizable to other centers. A recent randomized trial from the Hospital of the University of Pennsylvania found that the addition of a nighttime intensivist did not improve the quality or efficiency of care in the medical ICU but the extent to which results from a unit with heavy presence of daytime intensivist and protocolized care processes can be extrapolated to other centers is unclear (14).Despite some remaining uncertainties, there is now substantial empirical evidence that exposures to several potentially preventable risk factors during a hospital admission can increase the risk of developing ARDS and that the implementation of common sense protocols to improve standardization of care and reduce rates of exposures can substantially reduce the prevalence of ARDS. Given the limited options for treating ARDS, committing concerted effort toward prevention seems likely to be a high-yield, low-risk, and advisable strategy. With