Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery
Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery
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DOI：
10.1001/jama.281.14.1310
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发表时间：
1999-04-14
影响因子：
120.7
通讯作者：
Bass, E
中科院分区：
文献类型：
--
作者：
Pronovost, PJ;Jenckes, MW;Bass, E
背景重症监护病房（ICU）的发病率和死亡率在不同机构之间差异很大，但ICU结构和护理过程是否会影响这些outcome. ObjectiveTo确定ICU的组织特征是否与腹主动脉手术患者的临床和经济结局相关，这些患者通常;在ICU接受护理。设计观察性研究，回顾性收集患者数据，前瞻性收集ICU数据。设置所有马里兰州医院进行腹主动脉手术，1994年1月至1996年12月，我们分析了马里兰州非联邦急症护理医院的患者出院数据，这些患者的主要手术代码为腹主动脉手术（n = 2987）我们通过调查马里兰州46家进行腹主动脉瘤手术的医院的ICU医学主任，获得了有关ICU组织特征的信息。手术三十九（85%）的ICU主任完成了这项survey.Main结果测量住院死亡率和医院和ICU的住院时间longthstay.Results对于接受腹主动脉手术的患者，住院死亡率各医院从0%到66%不等。在调整患者人口统计学、共病、疾病严重程度、医院和外科医生数量以及医院特征的多变量分析中，ICU医生不进行每日查房与院内死亡率增加3倍相关（比值比[OR]，3.0; 95%置信区间[CI]，1.9-4.9）。此外，没有ICU医生的每日查房与心脏骤停的风险增加有关（OR，2.9; 95% CI，1.2-7.0），急性肾衰竭（OR，2.2; 95%CI，1.3-3.9）、败血症（OR，1.8，95%CI，1.2-2.6）、血小板输注（OR，6.4; 95%CI，3.2-12.4）和重新插管（OR，2.0; 95%CI，1.0-4.1）。ICU医生没有每天查房，ICU护士与患者的比例小于1：2，没有每月审查的发病率和死亡率，并拔管患者在手术室与增加的资源use.Conclusions ICU的组织特征与医院之间的差异腹主动脉手术的结果。临床医生和医院领导应考虑ICU组织特征对高危手术患者结局的潜在影响。
Context Morbidity and mortality rates in intensive care units (ICUs) vary widely among institutions, but whether ICU structure and care processes affect these outcomes is unknown.Objective To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically; receive care in an ICU.Design Observational study, with patient data collected retrospectively and ICU data collected prospectively.Setting All Maryland hospitals that performed abdominal aortic surgery from 1994 to 1996.Patients and Participants We analyzed hospital discharge data for patients in nonfederal acute care hospitals in Maryland who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 (n = 2987) We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine (85%) of the ICU directors completed this survey.Main Outcome Measures In-hospital mortality and hospital and ICU length of stay.Results For patients undergoing abdominal aortic surgery, in-hospital mortality varied among hospitals from 0% to 66%. In multivariate analysis adjusted for patient demographics, comorbid disease, severity of illness, hospital and surgeon volume, and hospital characteristics, not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.9). Furthermore, not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8, 95 % CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2.0; 95% CI, 1.0-4.1). Not having daily rounds by an ICU physician, having an ICU nurse-patient ratio of less than 1:2, not having monthly review of morbidity and mortality, and extubating patients in the operating room were associated with increased resource use.Conclusions Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery. Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations.