Hospital Strain and Variation in Sepsis ICU Admission Practices and Associated Outcomes.
Hospital Strain and Variation in Sepsis ICU Admission Practices and Associated Outcomes.
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DOI：
10.1097/cce.0000000000000858
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发表时间：
2023-02
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了解脓毒症患者的应变-过程-结果关系在不同医院之间的差异。回顾性队列研究，使用经验证的医院容量应变指数作为院内工具变量，控制ICU与病房入院，按医院分层。2013年至2018年，美国27家医院。不需要生命支持治疗的脓毒症高急性急诊科患者。没有。各应变十分位数的ICU入院的平均预测概率范围为4.9%（无生命支持的脓毒症最低ICU利用医院）至61.2%（无生命支持的脓毒症最高ICU利用医院）。最低和最高菌株十分位数之间的ICU入院预测概率差异范围从9.0%（菌株最不敏感的医院）到45.2%（菌株最敏感的医院）。在汇总分析中，急诊科脓毒症患者（n = 90，150）与病房相比，如果最初入住ICU，则中位住院时间（LOS）长1.3天，但在27家研究医院中（n = 517- 6，564），这种效果从缩短9.0天（95%CI，-10.8至-7.2; p < 0.001）到延长19.0天（95%CI，16.7-21.3; p < 0.001）。ICU住院死亡率与住院死亡率的相应范围显示，脓毒症患者的比值比（OR）为0.16（95%CI，0.03-0.99; p = 0.04）至4.62（95%CI，1.16-18.22; p = 0.02）（合并OR = 1.48）。不需要生命支持治疗的脓毒症患者的ICU入院率、ICU入院决策对医院容量紧张的敏感程度以及ICU入院与医院LOS和医院死亡率的相关性存在显著的院内差异。在危重病和急性护理研究设计和解释中，医院水平的异质性应与患者水平的异质性一起考虑。
To understand how strain-process-outcome relationships in patients with sepsis may vary among hospitals. Retrospective cohort study using a validated hospital capacity strain index as a within-hospital instrumental variable governing ICU versus ward admission, stratified by hospital. Twenty-seven U.S. hospitals from 2013 to 2018. High-acuity emergency department patients with sepsis who do not require life support therapies. None. The mean predicted probability of ICU admission across strain deciles ranged from 4.9% (lowest ICU-utilizing hospital for sepsis without life support) to 61.2% (highest ICU-utilizing hospital for sepsis without life support). The difference in the predicted probabilities of ICU admission between the lowest and highest strain deciles ranged from 9.0% (least strain-sensitive hospital) to 45.2% (most strain-sensitive hospital). In pooled analyses, emergency department patients with sepsis (n = 90,150) experienced a 1.3-day longer median hospital length of stay (LOS) if admitted initially to the ICU compared with the ward, but across the 27 study hospitals (n = 517-6,564), this effect varied from 9.0 days shorter (95% CI, –10.8 to –7.2; p < 0.001) to 19.0 days longer (95% CI, 16.7–21.3; p < 0.001). Corresponding ranges for inhospital mortality with ICU compared with ward admission revealed odds ratios (ORs) from 0.16 (95% CI, 0.03–0.99; p = 0.04) to 4.62 (95% CI, 1.16–18.22; p = 0.02) among patients with sepsis (pooled OR = 1.48). There is significant among-hospital variation in ICU admission rates for patients with sepsis not requiring life support therapies, how sensitive those ICU admission decisions are to hospital capacity strain, and the association of ICU admission with hospital LOS and hospital mortality. Hospital-level heterogeneity should be considered alongside patient-level heterogeneity in critical and acute care study design and interpretation.