Old Habits Die Hard: Do Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction Need an Intensive Care Unit?
Old Habits Die Hard: Do Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction Need an Intensive Care Unit?
复制标题
旧习难改：稳定的非ST段抬高型心肌梗死患者需要重症监护室吗？
DOI：
10.1161/circoutcomes.120.007700
复制
发表时间：
2021
期刊：
影响因子：
--
通讯作者：
Valley,ThomasS
中科院分区：
文献类型：
--
作者：
Thompson,AndreaD;Valley,ThomasS
汤普森和瓦利； NSTEMI 和 ICU 使用 入住 ICU 的 NSTEMI 患者的历史平均水平约为 40%。作者详细描述了最佳实践警报 (BPA) 嵌入式风险评分计算器急性冠脉治疗和干预结果网络 (ACTION) ICU 的实施，以支持临床医生的决策。 8 ACTION-ICU 评分通过突出临床特征（心力衰竭的体征或症状、初始肌酐、心率、血压）、患者特征（慢性肺病、年龄和既往血运重建）和缺血特征（新发 ST 段压低和初始肌钙蛋白）来预测需要 ICU 护理的风险（定义为心脏骤停、休克、高度房室传导阻滞、呼吸衰竭、中风或死亡）。 8 他们的理论是，将 ACTION-ICU 评分整合到电子健康记录中将减少 ICU 的使用。然而，实施后，BPA 与 ICU 利用率的变化无关。干预措施也没有影响临床结果，包括院内死亡率、ICU 转诊、ICU 住院时间和住院时间。尽管结果为负面，但本研究得出了几个重要的发现。这项工作的主要优势包括其新颖性以及对电子健康记录集成预测分析的现实评估。虽然已经制定了许多风险评分来影响 ICU 的使用，但很少被实施到日常实践中。这项研究为未来寻求优化 ICU 使用的研究奠定了基础。然而，也许这项研究最有趣的方面是推测 BPA 实施中的关键决策点、学习作者的经验以及考虑未来改进的潜在途径。在本例中，最明显的是，由于急诊科临床医生对 BPA 的使用率较低，干预措施受到限制。造成这种情况的原因可能有多种，与 BPA 本身以及使用它的临床医生有关。
Thompson and Valley; NSTEMI and ICU Use of NSTEMI patients admitted to their ICU, from a historical average of about 40%. The authors described in detail the implementation of a best practice alert (BPA)–embedded risk score calculator Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU to support clinician decision-making. 8 The ACTION-ICU score predicts the risk of developing the need for ICU care (defined as cardiac arrest, shock, high-grade atrioventricular block, respiratory failure, stroke, or death) by highlighting clinical features (signs or symptoms of heart failure, initial creatinine, heart rate, blood pressure), patient features (chronic lung disease, age, and prior revascularization), and features of ischemia (new ST-segment depression and initial troponin). 8 They theorized that integrating the ACTION-ICU score into the electronic health record would reduce ICU use. Yet, after implementation, the BPA was not associated with a change in ICU utilization. The intervention also did not affect clinical outcomes, including in-hospital mortality, ICU transfer, ICU length of stay, and hospital length of stay.Despite the negative outcome, this study yields several important findings. Key strengths of this work include its novelty and its real-world evaluation of an electronic health record–integrated predictive analytic. While many risk scores have been developed to influence ICU use, few have been implemented into routine practice. This study lays a foundation onto which future studies seeking to optimize ICU use can build. Yet, perhaps the most intriguing aspects of this study are in speculating about key decision points within the implementation of a BPA, learning from the author’s experience, and considering potential avenues for improvement going forward. Most clearly in this case, the intervention was limited by the low use of the BPA by emergency department clinicians. There may be several reasons for this, related to the BPA itself and to the clinicians using it.