Evaluation Following Staggered Implementation of the "Rethinking Critical Care" ICU Care Bundle in a Multicenter Community Setting.
Evaluation Following Staggered Implementation of the "Rethinking Critical Care" ICU Care Bundle in a Multicenter Community Setting.
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DOI：
10.1097/ccm.0000000000001462
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发表时间：
2016-03
影响因子：
8.8
通讯作者：
Escobar GJ
中科院分区：
文献类型：
--
作者：
Liu V;Herbert D;Foss-Durant A;Marelich GP;Patel A;Whippy A;Turk BJ;Ragins AI;Kipnis P;Escobar GJ
评估在社区环境中实施“重新思考重症监护”（RCC） ICU护理包后的过程指标和结果。2009年1月1日至2013年8月30日期间，在Kaiser Permanente北加州综合医疗保健服务系统的三家医院的重症监护病房（ICU）住院的患者。RCC ICU护理包旨在通过专注于谵谵症、镇静、机械通气、活动、走动和协调护理的管理来减少潜在的可预防并发症。2011年10月至2012年11月期间，RCC的实施是交错进行的。我们基于电子病历数据测量了实施指标，并使用多变量回归模型评估了实施对死亡率的影响。我们评估了19,872例患者的24,886次ICU首次发作。实施后，一些过程指标（例如，通风启动和停止时间）以高速率实现，而其他过程指标（例如，行走距离）在研究后期可用，显示出依从性的急剧增加。实施前后未调整死亡率分别从12.3%降至10.9% （p值<0.01）。与实施前相比，实施后医院死亡率的调整优势比为0.85(95%可信区间为0.73-0.99)，30天死亡率的调整优势比为0.88 （95% CI为0.80-0.97）。然而，实施RCC前后的死亡率趋势无显著差异。机械通气的平均持续时间和住院时间在实施后也没有表现出更大的下降。RCC的实施与实践的改变有关，短期死亡率降低了12%至15%。然而，这些发现可能代表了对仍处于实施中期阶段的实践变化和结果的评估，不能直接归因于捆绑实施的要素。
To evaluate process metrics and outcomes following implementation of the ‘Rethinking Critical Care’ (RCC) ICU care bundle in a community setting. Patients admitted to the intensive care unit (ICU) at three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system between January 1, 2009 and August 30, 2013. The RCC ICU care bundle is designed to reduce potentially preventable complications by focusing on the management of delirium, sedation, mechanical ventilation, mobility, ambulation, and coordinated care. RCC implementation occurred in a staggered fashion between October 2011 and November 2012. We measured implementation metrics based on electronic medical record data and evaluated the impact of implementation on mortality with multivariable regression models. We evaluated 24,886 first ICU episodes in 19,872 patients. After implementation, some process metrics (e.g., ventilation start and stop times) were achieved at high rates while others (e.g., ambulation distance), available late in the study period, showed steep increases in compliance. Unadjusted mortality decreased from 12.3% to 10.9% (p-value<0.01) before and after implementation, respectively. The adjusted odds ratio for hospital mortality after implementation was 0.85 (95% confidence interval, 0.73–0.99) and for thirty-day mortality was 0.88 (95% CI, 0.80–0.97) compared with before implementation. However, the mortality rate trends were not significantly different before and after RCC implementation. The mean duration of mechanical ventilation and hospital stay also did not demonstrate incrementally greater declines after implementation. RCC implementation was associated with changes in practice and a 12% to 15% reduction in the odds of short-term mortality. However, these findings may represent an evaluation of changes in practices and outcomes still in the mid-implementation phase and cannot be directly attributed to the elements of bundle implementation.