Pediatric critical care training programs have a positive effect on pediatric intensive care mortality
Pediatric critical care training programs have a positive effect on pediatric intensive care mortality
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DOI：
10.1097/00003246-199710000-00011
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发表时间：
1997-10-01
影响因子：
8.8
通讯作者：
Ruttimann, UE
中科院分区：
文献类型：
--
作者：
Pollack, MM;Patel, KM;Ruttimann, UE
目标：比较儿科重症监护病房（ICU）的严重程度和诊断调整死亡率，ICU配备了儿科重症监护培训的医生，以及儿科住院医生，与儿科ICU仅配备儿科住院医生的死亡率。设计：队列研究。设置：16名志愿儿科ICU，8名有重症监护奖学金，8名无此类计划。患者：连续入院，直到至少有14例死亡occured.Interventions：无。测量和主要结果：描述性数据和儿科死亡风险评分收集。每例患者的严重程度和诊断调整的死亡风险通过独立样本中开发的预测因子计算。通过对儿科ICU的观察/预测死亡率进行排名，在机构层面分析了奖学金计划的影响，在患者层面，通过将训练因子纳入预测模型。通过严重程度调整后的比值比比较了两种类型儿科ICU中监测和治疗方式的使用。八个奖学金儿科ICU收治了2，744人（145人死亡），八个非奖学金儿科ICU收治了3，006人（150人死亡）。两个儿科ICU的机构特征没有差异。原始死亡率相似（团契5.28%;非团契4.99%，p = 0.714）。机构层面的分析表明，奖学金儿科ICU的表现优于非奖学金儿科ICU;奖学金儿科ICU的排名优于没有此类项目的儿科ICU（Wilcoxon秩和检验，p = 0.020）。然而，排名最好和最差的儿科ICU都有奖学金。患者水平的分析也表明，结果显着影响的儿科ICU的奖学金状态。使用两种不同的患者水平分析方法，研究金儿科ICU与非研究金儿科ICU的死亡几率分别为0.592（95%置信区间0.468至0.749，p = .0001）和0.714（95%置信区间0.529至0.964，p = .028）。儿科ICU与奖学金计划进行更多的（p < .05）侵入性监测，包括动脉内导管和中心静脉压导管，和更多的技术治疗，如mechanical ventilation.Conclusions：儿科ICU与重症监护奖学金计划通常与更好的风险调整后的死亡率比儿科ICU没有这样的奖学金培训计划。这种影响的原因需要更深入的研究。此类培训计划的存在或不存在并不能保证表现的上级或低劣。
Objective: Comparison of severity and diagnosis adjusted mortality rates from pediatric intensive care units (ICUs) staffed by physicians training in pediatric critical care, as well as pediatric residents, with mortality rates from pediatric ICUs staffed with only pediatric residents.Design: Cohort study.Setting: Sixteen volunteer pediatric ICUs, eight with critical care fellowships, and eight without such programs.Patients: Consecutive admissions until at least 14 deaths oc curred at each site.Interventions: None.Measurements and Main Results: Descriptive data and Pediatric Risk of Mortality scores were collected. Severity and diagnosis-adjusted mortality risk for each patient was computed by a predictor developed in an independent sample. The effect of fellowship programs was analyzed at the institution level by ranking the pediatric ICUs in terms of observed/predicted mortality rates, and, at the patient level, by including a training factor into the predictor model. The use of monitoring and therapeutic modalities was com pared in the two types of pediatric ICUs by severity-adjusted odds ratios.There were 2,744 admissions (145 deaths) to the eight fellowship pediatric ICUs and 3,006 admissions (150 deaths) to the eight nonfellowship pediatric ICUs. Institutional characteristics were not different between the two pediatric ICU sets. The raw mortality rates were similar (fellowship 5.28%; nonfellowship 4.99%, p = .714). Institution-level analyses indicated that fellowship pediatric ICUs performed better than nonfellowship pediatric ICUs; fellow ship pediatric ICUs ranked better than pediatric ICUs without Such programs (Wilcoxon rank sum test, p = .020). However, both the best and the worst ranked pediatric ICUs had fellowships. Patient-level analyses also indicated that outcome was significantly influenced by the fellowship status of the pediatric ICU. Using two different patient level analytic approaches, the odds of dying in a fellowship pediatric ICU vs. a nonfellowship pediatric ICU were 0.592 (95% confidence interval 0.468 to 0.749, p = .0001) and 0.714 (95% confidence interval 0.529 to 0.964, p = .028). Pediatric ICUs with fellowship programs performed more (p < .05) invasive monitoring, including intra-arterial catheters and central venous pressure catheters, and more technological therapies such as mechanical ventilation.Conclusions: Pediatric ICUs with critical care fellowship programs are generally associated with better risk-adjusted mortality rates than pediatric ICUs without such fellowship training pro grams. The cause for this effect requires a more in-depth study. The presence or absence of such training programs does not guarantee superior or inferior performance.