Ghorra S, Reinert S E, Cioffi W, Buczko G, Simms H H
Division of Surgical Critical Care, Rhode Island Hospital, Providence 02903, USA.
Ann Surg. 1999 Feb;229(2):163-71. doi: 10.1097/00000658-199902000-00001.
To compare the effect on clinical outcome of changing a surgical intensive care unit from an open to a closed unit.
The study was carried out at a surgical intensive care unit in a large tertiary care hospital, which was changed on January 1, 1996, from an open unit, where private attending physicians contributed and controlled the care of their patients, to a closed unit, where patients' medical care was provided only by the surgical critical care team (ABS or ABA board-certified intensivists). A retrospective review was undertaken over 6 consecutive months in each system, encompassing 274 patients (125 in the open-unit period, 149 in the closed-unit period). Morbidity and mortality were compared between the two periods, along with length-of-stay (LOS) and number of consults obtained. A set of independent variables was also evaluated, including age, gender, APACHE III scores, the presence of preexisting medical conditions, the use of invasive monitoring (Swan-Ganz catheters, central and arterial lines), and the use of antibiotics, low-dose dopamine (LDD) for renal protection, vasopressors, TPN, and enteral feeding.
Mortality (14.4% vs. 6.04%, p = 0.012) and the overall complication rate (55.84% vs. 44.14%, p = 0.002) were higher in the open-unit group versus the closed-unit group, respectively. The number of consults obtained was decreased (0.6 vs. 0.4 per patient, p = 0.036), and the rate of occurrence of renal failure was higher in the open-unit group (12.8% vs. 2.67%, p = 0.001). The mean age of the patients was similar in both groups (66.48 years vs. 66.40, p = 0.96). APACHE III scores were slightly higher in the open-unit group but did not reach statistical significance (39.02 vs. 36.16, p = 0.222). There were more men in the first group (63.2% vs. 51.3%). The use of Swan-Ganz catheters or central and arterial lines were identical, as was the use of antibiotics, TPN, and enteral feedings. The use of LDD was higher in the first group, but the LOS was identical.
Conversion of a tertiary care surgical intensive care unit from an open to closed environment reduced dopamine usage and overall complication and mortality rates. These results support the concept that, when possible, patients in surgical intensive care units should be managed by board-certified intensivists in a closed environment.
比较将外科重症监护病房从开放式改为封闭式对临床结局的影响。
该研究在一家大型三级护理医院的外科重症监护病房进行，该病房于1996年1月1日从开放式病房转变为封闭式病房。在开放式病房中，私人主治医师参与并控制其患者的护理；在封闭式病房中，患者的医疗护理仅由外科重症监护团队（美国外科学会或美国麻醉学会认证的重症医学专家）提供。对每个系统连续6个月进行回顾性研究，涵盖274例患者（开放式病房期间125例，封闭式病房期间149例）。比较两个时期的发病率、死亡率、住院时间（LOS）和会诊次数。还评估了一组自变量，包括年龄、性别、急性生理与慢性健康状况评分系统III（APACHE III）评分、既往存在的医疗状况、侵入性监测的使用情况（Swan-Ganz导管、中心静脉和动脉导管）以及抗生素、用于肾脏保护的低剂量多巴胺（LDD）、血管升压药、全胃肠外营养（TPN）和肠内营养的使用情况。
开放式病房组的死亡率（14.4%对6.04%，p = 0.012）和总体并发症发生率（55.84%对44.14%，p = 0.002）分别高于封闭式病房组。获得的会诊次数减少（每位患者0.6次对0.4次，p = 0.036），开放式病房组肾衰竭的发生率更高（12.8%对2.67%，p = 0.001）。两组患者的平均年龄相似（66.48岁对66.40岁，p = 0.96）。开放式病房组的APACHE III评分略高，但未达到统计学意义（39.02对36.16，p = 0.222）。第一组男性更多（63.2%对51.3%）。Swan-Ganz导管或中心静脉和动脉导管的使用情况相同，抗生素、TPN和肠内营养的使用情况也相同。第一组LDD的使用更高，但住院时间相同。
将三级护理外科重症监护病房从开放式环境转变为封闭式环境可减少多巴胺的使用以及总体并发症和死亡率。这些结果支持这样的观点，即外科重症监护病房的患者在可能的情况下应由认证的重症医学专家在封闭环境中进行管理。
