Nighttime intensivist staffing and mortality among critically ill patients.
Nighttime intensivist staffing and mortality among critically ill patients.
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DOI：
10.1056/nejmsa1201918
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发表时间：
2012-05-31
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影响因子：
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通讯作者：
Kahn JM
中科院分区：
文献类型：
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作者：
Wallace DJ;Angus DC;Barnato AE;Kramer AA;Kahn JM
医院越来越多地采用24小时重症监护医生配置作为改善重症监护室（ICU）结果的策略。然而，夜间重症监护医师与ICU护理质量改善的相关程度尚不清楚。我们进行了一项回顾性队列研究，涉及2009年至2010年参加急性生理学和慢性健康评价（APACHE）临床信息系统的ICU，将ICU人员配置实践调查与成人ICU入院患者水平结局数据联系起来。多变量模型用于评估夜间重症监护人员配置与ICU患者住院死亡率之间的关系，并对日间重症监护人员配置、疾病严重程度和病例组合进行调整。我们在宾夕法尼亚州的第二个以人群为基础的医院队列中进行了验证性分析，其中可获得的数据不太详细。使用APACHE数据库进行的分析包括25家医院49个ICU的65，752名患者。在低强度日间工作人员的ICU中，夜间重症监护人员的配备与风险调整后的院内死亡率降低相关（死亡的调整优势比为0.62; P = 0.04）。在高强度日间工作人员的ICU中，夜间重症监护人员的配备对风险调整后的住院死亡率没有任何好处（比值比，1.08; P = 0.78）。在验证队列中，日间人员配备、夜间人员配备和住院死亡率之间存在类似的关系。夜间工作人员和日间工作人员之间的相互作用不显著（P = 0.18），但结果的方向与APACHE队列中的结果相似。在低强度的日间人员配置模式中增加夜间重症监护人员与死亡率降低相关。然而，在高强度日间工作人员的ICU中未观察到死亡率降低。（由国家心脏，肺和血液研究所资助。
Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown. We conducted a retrospective cohort study involving ICUs that participated in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical information system from 2009 through 2010, linking a survey of ICU staffing practices with patient-level outcomes data from adult ICU admissions. Multivariate models were used to assess the relationship between nighttime intensivist staffing and in-hospital mortality among ICU patients, with adjustment for daytime intensivist staffing, severity of illness, and case mix. We conducted a confirmatory analysis in a second, population-based cohort of hospitals in Pennsylvania from which less detailed data were available. The analysis with the use of the APACHE database included 65,752 patients admitted to 49 ICUs in 25 hospitals. In ICUs with low-intensity daytime staffing, nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for death, 0.62; P = 0.04). Among ICUs with high-intensity daytime staffing, nighttime intensivist staffing conferred no benefit with respect to risk-adjusted in-hospital mortality (odds ratio, 1.08; P = 0.78). In the verification cohort, there was a similar relationship among daytime staffing, nighttime staffing, and in-hospital mortality. The interaction between nighttime staffing and daytime staffing was not significant (P = 0.18), yet the direction of the findings were similar to those in the APACHE cohort. The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing. (Funded by the National Heart, Lung, and Blood Institute.)