Goldfrad C, Rowan K
Intensive Care National Audit & Research Centre, London, UK.
Lancet. 2000 Apr 1;355(9210):1138-42. doi: 10.1016/S0140-6736(00)02062-6.
It is generally believed that pressure for beds on intensive-care units (ICUs) has increased in the UK. This study used discharge at night as a proxy measure to investigate pressure.
Night was defined in two ways: "out of office hours' from 2200 to 0659 h and "the early hours of the morning" from 0000 to 0459 h. The rate of discharge at night was compared for 21 295 adult admissions to 62 ICUs covering the period 1995-98 with 10806 admissions to 26 ICUs covering the period 1988-90. With data solely from 1995-98, the consequences of discharge at night and premature discharge were investigated.
Overall, 2269 (21.0%) admissions did not survive the ICU in 1988-90 compared with 4487 (21.1%) in 1995-98. Of ICU survivors, 2.7% were discharged at night (2200-0659 h) in 1988-90 compared with 6.0% in 1995-98. In 1995-98, night discharges (2200-0659 h) had a higher crude (odds ratio 1.46, 95% CI 1.18-1.80) and case-mix adjusted (1.33, 1.06-1.65) ultimate hospital mortality. Higher odds ratios were observed when the definition of night was 0000-0459 h. Premature discharge was commoner at night, 42.6% vs 5.0% and its importance was apparent when incorporated into the logistic-regression model (premature discharge 1.35, 1.10-1.65; night discharge 1.17, 0.92-1.49).
Night discharges from ICU are increasing in the UK. This practice is of concern because patients discharged at night fare significantly worse than those discharged during the day. Night discharges are more likely to be "premature" in the view of the clinicians involved. The implication of these results is that many hospitals have insufficient intensive-care beds. In deciding whether or not to invest more resources in intensive care we must, however, consider the cost-utility of this particular service compared with other ways that additional resources could be used.
人们普遍认为，英国重症监护病房（ICU）的床位压力有所增加。本研究以夜间出院作为替代指标来调查压力情况。
夜间的定义有两种：“非办公时间”为22:00至06:59，“凌晨时段”为00:00至04:59。比较了1995 - 1998年期间62个ICU的21295例成人入院患者与1988 - 1990年期间26个ICU的10806例入院患者的夜间出院率。利用1995 - 1998年的单独数据，研究了夜间出院和过早出院的后果。
总体而言，1988 - 1990年期间，2269例（21.0%）入院患者未在ICU存活，而1995 - 1998年期间为4487例（21.1%）。在ICU存活的患者中，1988 - 1990年期间2.7%在夜间（夜间22:00至06:59）出院，而1995 - 1998年期间为6.0%。在1995 - 1998年，夜间出院（22:00至06:59）的患者粗死亡率（优势比1.46，95%可信区间1.18 - 1.80）和病例组合调整后的最终医院死亡率（1.33，1.06 - 1.65）更高。当夜间定义为00:00至04:59时，观察到更高的优势比。夜间过早出院更为常见，分别为42.6%和5.0%，当纳入逻辑回归模型时，其重要性明显（过早出院1.35，1.10 - 1.65；夜间出院1.17，0.92 - 1.49）。
在英国，ICU夜间出院的情况正在增加。这种做法令人担忧，因为夜间出院的患者情况明显比白天出院的患者差。从相关临床医生的角度来看，夜间出院更有可能是“过早”的。这些结果表明，许多医院的重症监护床位不足。然而，在决定是否在重症监护方面投入更多资源时，我们必须考虑这项特定服务的成本效益，与其他可以使用额外资源的方式进行比较。
