Regionalized Critical Care May Be Feasible, But Will It Improve Outcomes?
Regionalized Critical Care May Be Feasible, But Will It Improve Outcomes?
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区域化重症监护可能是可行的，但它会改善结果吗？
DOI：
10.1097/ccm.0000000000001174
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发表时间：
2015
影响因子：
8.8
通讯作者：
Brown,SydneyES
中科院分区：
文献类型：
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作者：
Brown,SydneyES
区域化重症监护是一种系统，其中病情最重的患者在前往医院的途中被分流到转诊医院的专门ICU。这种系统目前被用于创伤和心脏骤停患者，并已证明具有益处（1，2），并且它有可能改善其他危重患者人群的结局以及转诊和非转诊医院的效率（2-4）。因此，美国重症监护专业协会和医学研究所也提倡对病情最严重的重症患者进行区域化（5，6）。然而，关于区域化的可行性，包括院前分诊对紧急医疗服务（EMS）运输时间和ICU占用率的影响，文献中存在显著差距。值得关注的是，除了最近的医院外，任何医院的分诊，院前运输时间可能会增加，以至于在转诊中心接受护理的好处可能会被接受护理的延迟所抵消，或者转诊中心可能会变得过于紧张，无法为这些患者提供最佳护理（7-9）。Seymour等人（11）在这期《重症监护医学》中的研究试图解决这些问题。使用超过100，000名在华盛顿州金县14家医院接受治疗的成人非创伤、非心脏骤停、危重患者的管理数据集，Seymour和他的同事（10，11）使用急救医疗技术人员在现场使用的经验证的院前风险评分模拟了一个到指定转诊中心的院前分诊系统。各种情况下，包括病情最重的病人转诊中心和病情较轻的病人到最近的医院与可用的病床进行了评估，院前运输时间和ICU占用的影响。EMS事件被地理定位，谷歌地图和ArcGIS（http：//www.北极星com）被用来确定和时间的路线采取的目的地医院，占波动的交通模式（12）。
Regionalized critical care is a system in which the sickest patients are triaged while en route to the hospital to specialized ICUs located in referral hospitals. Such a system is currently utilized for trauma and cardiac arrest patients with demonstrated benefits (1, 2), and it has the potential to both improve outcomes among other populations of critically ill patients and the efficiency of referral and nonreferral hospitals (2–4). As a result, US critical care professional societies and the Institute of Medicine have advocated the adoption of regionalization for the sickest critically ill patients as well (5, 6).However, there are significant gaps in the literature regarding the feasibility of regionalization, including the effects of prehospital triage on emergency medical services (EMS) transport times and on ICU occupancy. The concern is that with triage to any hospital other than the closest available, prehospital transport times could increase such that the benefits of receiving care at a referral center might be outweighed by delays in care received or that referral centers could become too strained to provide optimal care to these patients (7–9). The study by Seymour et al (11) in this issue of Critical Care Medicine seeks to address these questions. Using an administrative dataset of over 100,000 adult nontrauma, non–cardiac arrest, critically ill patients who received care in 14 hospitals located in King County, WA, Seymour and his colleagues (10, 11) simulated a system of prehospital triage to designated referral centers using a validated prehospital risk score employed in the field by emergency medical technicians. Various scenarios involving up-triage of the sickest patients to referral centers and down-triage of less sick patients to the nearest hospital with an available bed were assessed for effects on prehospital transport time and ICU occupancy. EMS incidents were geolocated, and Google Maps and ArcGIS (http://www. arcgis. com) were used to determine and time routes taken to destination hospitals, accounting for fluctuations in traffic patterns (12).