Mortality among appropriately referred patients refused admission to intensive-care units
Mortality among appropriately referred patients refused admission to intensive-care units
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DOI：
10.1016/s0140-6736(96)10018-0
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发表时间：
1997-07-05
期刊：
影响因子：
168.9
通讯作者：
McPherson, K
中科院分区：
文献类型：
--
作者：
Metcalfe, MA;Sloggett, A;McPherson, K
背景重症监护的提供对于临床医生和公众来说是一个令人困惑的问题。由于提供这种服务的费用高昂，人们对明显缺乏床位和收治的病人是否适当的关切有所缓和。作为英国卫生部委托进行的一项研究的一部分，我们测试的假设，有多余的死亡率之间的患者谁被拒绝入院intensive-care units.Methods所有转介到6个重症监护病房与不同数量的病床进行了监测，在3个月的时间。从家庭医生处获得所有已知出院时存活的患者首次转诊后90天的死亡率数据。在可能的情况下，我们调整了混杂因素，包括年龄、性别、转诊的适当性、疾病严重程度、手术和急诊类别以及床位供应。我们做了多因素分析，多元Logistic回归比较调整后的90天死亡率的患者谁被拒绝入院，并为那些admitted.Findings 480例患者入院，165被拒绝入院。转诊后90天，入院组有178例（37%）死亡，拒绝组有75例（46%）死亡。经过多变量校正后，113例适当转诊重症监护但拒绝进入首选重症监护病房的患者，与疾病严重程度中等的APACHE II评分的适当入院病例组相比，死亡的相对风险为1.6（95%CI 10-2.5）。年龄、评估的治疗或监测干预需求以及急诊状态也是导致所有转诊患者死亡率差异的原因。床位供应并没有显着的超额mortality.Interpretation虽然这项研究是观察和病例组合的调整是不完整的，我们发现一个较高的归因于死亡率的患者谁被拒绝重症监护，特别是急诊病例。我们质疑单靠提供更多病床是否解决问题的方法，并认为有迫切需要制订更适当的入院及出院准则。
Background The provision of intensive care is a perplexing issue for clinicians and the public. Concerns about the apparent lack of beds and the appropriateness of the patients admitted are tempered by the high cost of providing this service. As part of a study commissioned by the UK Department of Health, we tested the hypothesis that there is excess mortality among patients who are refused admission to intensive-care units.Methods All referrals to six intensive-care units with different numbers of beds were monitored during a 3-month period. Data on mortality 90 days after first referral were obtained from family physicians for all patients known to be alive at hospital discharge. We adjusted, where possible, for confounding, including for age, sex, appropriateness of referral, disease severity, surgery and emergency categories, and bed provision. We did multivariate analysis by multiple logistic regression to compare the adjusted 90-day mortality rates for patients who were refused admission and for those admitted.Findings 480 patients were admitted and 165 were refused admission. 90 days after referral there had been 178 (37%) deaths among the admitted group and 75 (46%) among the refused group. After multivariate adjustment, 113 patients appropriately referred for intensive care but refused admission to their first-choice intensive-care unit had a relative risk of death of 1.6 (95% CI 10-2.5), compared with the group of appropriately admitted cases with medium APACHE II scores for disease severity. Age, the assessed need for treatment or monitoring interventions, and emergency status also contributed to differences in mortality among all referrals. Bed provision did not contribute significantly to excess mortality.Interpretation Although this study is observational and case-mix adjustment is incomplete, we found a higher rate of attributable mortality in patients who were refused intensive care, particularly for emergency cases. We question whether the provision of more beds alone would be a solution and conclude that there is an urgent need for more appropriate admission and discharge criteria.