Benefits of ICU admission for patients with acute respiratory failure or sepsis: A mixed-methods study across 26 hospitals

急性呼吸衰竭（ARF）和脓毒症（急性呼吸衰竭最常见和致命的原因）患者 呼吸窘迫综合征）在美国甚至 当他们不需要生命支持的时候。然而，这些患者的ICU入院率差异很大 在医院之间，甚至在医院内部，由于床位的可用性。这种做法的差异性表明， 一些病人可能被“分流不足”到病房，而他们的结果可以通过送他们去改善， 直接到ICU（例如，由于更近的护士或呼吸治疗师监测）。其他患者可能会“过度- 当他们的结果和护理成本与直接将他们送到ICU一样好或更好时， 病房（例如，由于较少的谵妄或不动）。此外，确定这些“酌情”ICU中的哪一个 住院病人在病房得到同样或更好的治疗，将有助于及时进入ICU， 更严重的心肺衰竭和更明显的ICU入院指征。 为了通过优化ARF和/或脓毒症患者的分诊来改善他们的结果，本申请提出了一种方法， 对26家不同医院急诊科收治的患者进行了混合方法研究， 凯撒永久北方加州卫生系统和宾夕法尼亚大学卫生系统。我们 主要目的是确定哪些ARF和/或脓毒症患者从ICU住院中获益， 急诊科、病房和ICU的特点和护理过程有助于形成这种净ICU 效益一些方法上的创新将使我们能够实现这些目标，并克服关键的困难。 限制了先前的研究，试图确定哪些急性病患者受益于ICU入院。 首先，尽管所有先前的研究都使用了因果推理的方法，这些方法容易受到以下因素的干扰： 医院之间的不可测量的差异，我们将获得无偏的估计，哪些患者受益于ICU 或病房入院，通过模拟院内变量-分诊时ICU容量-作为 工具变量其次，尽管先前的研究无法确切确定哪些患者 结果适用于，我们的研究医院提供的颗粒状电子健康记录数据将使我们的 结果直接应用于特征明确的个体患者，促进个性化分诊决策。 第三，我们使用民族志和半结构化访谈的医院，获得大，小净ICU 福利将确定不同医院在ICU和病房实现改善结果的机制。 完成这项研究的目的将通过确定紧急情况下， 各科室、ICU和病房可以改善400多万住院美国人的治疗效果， ARF和/或脓毒症。这样的结果也将提供发展和测试分流所需的证据 算法，以改善ARF和/或脓毒症患者在急诊科就诊的结局。

Patients with acute respiratory failure (ARF) and sepsis (the most common and lethal cause of the acute respiratory distress syndrome) are commonly admitted to intensive care units (ICUs) in the United States even when they do not require life support. However, ICU admission rates for these patients vary considerably among hospitals and even within hospitals over time due to bed availability. This practice variability suggests that some patients may be “under-triaged” to wards when their outcomes could be improved by sending them directly to the ICU (e.g., due to closer nurse or respiratory therapist monitoring). Other patients may be “over- triaged” to ICUs when their outcomes and costs of care would be as good or better by sending them directly to wards (e.g., due to less delirium or immobility). Furthermore, determining which of these “discretionary” ICU admissions could be treated as well or better on wards would improve timely access to ICUs for patients with more advanced forms of cardiorespiratory collapse and more obvious indications for ICU admission. To improve outcomes for patients with ARF and/or sepsis by optimizing their triage, this application proposes a mixed-methods study of patients admitted through the emergency departments of 26 diverse hospitals in the Kaiser Permanente Northern California health system and the University of Pennsylvania Health System. Our primary goals are to determine which patients with ARF and/or sepsis benefit from ICU admission, and which emergency department, ward, and ICU characteristics and processes of care contribute to such net ICU benefits. Several methodological innovations will enable us to achieve these goals, and to surmount key limitations to prior studies that have sought to determine which acutely ill patients benefit from ICU admission. First, whereas all prior studies used approaches to causal inference that were susceptible to confounding by unmeasured differences among hospitals, we will obtain unbiased estimates of which patients benefit from ICU or ward admission by modeling a within-hospital variable – ICU capacity at the time of triage – as an instrumental variable. Second, although prior studies have been unable to determine exactly which patients the results apply to, the granular electronic health record data available across our study hospitals will enable our results to apply directly to well-characterized individual patients, promoting personalized triage decisions. Third, our use of ethnography and semi-structured interviews in hospitals that obtain large and small net ICU benefits will identify mechanisms by which different hospitals achieve improved outcomes in ICUs and wards. Completing the aims of this study will improve public health by identifying ways in which emergency departments, ICUs, and wards can improve outcomes for the more than 4 million Americans hospitalized each year with ARF and/or sepsis. Such results will also provide the evidence needed to develop and test triage algorithms to improve outcomes for patients with ARF and/or sepsis presenting to emergency departments.