Todd James, Bertoch David, Dolan Susan
Department of Epidemiology, The Children's Hospital, Denver, CO 80218, USA.
Arch Pediatr Adolesc Med. 2002 Nov;156(11):1086-90. doi: 10.1001/archpedi.156.11.1086.
To use a large national comparative database to measure the internal effect of a set of evidence-based bronchiolitis/viral pneumonia clinical care guidelines on clinical practice at a children's hospital, and to compare these changes with those at other children's hospitals.
Prospective cohort study with retrospective and concurrent (other hospital) controls.
The Children's Hospital, Denver, Colo.
Hospitalized children with bronchiolitis and/or viral pneumonia.
Our clinical guidelines focused on clear admission and discharge criteria, individualized transition-anticipating orders, and "prove it or don't use it" criteria for the use of respiratory syncytial virus testing, bronchodilators, chest physiotherapy, and ribavirin.
The effect of guideline implementation was determined by comparative measurement of internal changes in utilization and outcome (nosocomial infection rate) across time and by external comparison with other children's hospitals using standardized data from the Pediatric Health Information System database of the Child Health Corporation of America (Shawnee Mission, Kan).
Overall, 10 636 bronchiolitis/viral pneumonia cases were studied: 1302 at the index hospital and 9334 at the 7 comparison hospitals. Internally, the index hospital's residents and attending physicians responded favorably to the bronchiolitis/viral pneumonia care guidelines, resulting in decreases in targeted resource utilization. There were no fatalities, and the number of days in the intensive care unit decreased even though the mean severity of admitted cases increased significantly. Targeted utilization was favorably affected, whereas untargeted utilization was not. Nosocomial infections did not increase with a decreased use of respiratory syncytial virus testing. The index hospital differed favorably from other children's hospitals in several categories.
Evidence-based care guidelines can successfully influence utilization and clinical outcome.
利用一个大型全国性比较数据库，衡量一套基于证据的细支气管炎/病毒性肺炎临床护理指南对一家儿童医院临床实践的内部影响，并将这些变化与其他儿童医院的变化进行比较。
前瞻性队列研究，采用回顾性和同期（其他医院）对照。
科罗拉多州丹佛市儿童医院。
患有细支气管炎和/或病毒性肺炎的住院儿童。
我们的临床指南侧重于明确的入院和出院标准、个性化的过渡预期医嘱，以及呼吸道合胞病毒检测、支气管扩张剂、胸部物理治疗和利巴韦林使用的“证明其必要性或不使用”标准。
通过比较不同时间内利用情况和结局（医院感染率）的内部变化，并与其他儿童医院进行外部比较（使用美国儿童健康公司儿科健康信息系统数据库（堪萨斯州肖尼使命）的标准化数据），来确定指南实施的效果。
总体而言，共研究了10636例细支气管炎/病毒性肺炎病例：索引医院1302例，7家对照医院9334例。在内部，索引医院的住院医师和主治医师对细支气管炎/病毒性肺炎护理指南反应良好，导致目标资源利用率下降。没有死亡病例，尽管入院病例的平均严重程度显著增加，但重症监护病房的住院天数减少了。目标利用率受到有利影响，而非目标利用率则没有。医院感染并未因呼吸道合胞病毒检测使用减少而增加。索引医院在几个类别上与其他儿童医院相比表现良好。
基于证据的护理指南可以成功影响利用率和临床结局。
