Pronovost Peter J, Angus Derek C, Dorman Todd, Robinson Karen A, Dremsizov Tony T, Young Tammy L
Department of Critical Care Medicine, Hopkins University, Baltimore, Md, USA.
JAMA. 2002 Nov 6;288(17):2151-62. doi: 10.1001/jama.288.17.2151.
Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear.
To evaluate the association between ICU physician staffing and patient outcomes.
We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001).
We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU.
We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment.
High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS.
重症监护病房（ICU）的医师配备差异很大，其与患者预后的关联尚不清楚。
评估ICU医师配备与患者预后之间的关联。
我们检索了MEDLINE（1965年1月1日至2001年9月30日），查找以下医学主题词（MeSH）：重症监护病房、ICU、卫生资源/利用、住院治疗、医务人员、医院组织与管理、人员配备与排班、住院时间以及LOS。我们还使用了以下文本词：人员配备、重症医学专家、危重症、护理和专科医生。为了识别观察性研究，我们添加了MeSH词病例对照研究和回顾性研究。尽管我们检索了非英语文献，但仅审阅了英语文章。我们还通过Internet Grateful Med、Cochrane图书馆检索了EMBASE、HealthStar（卫生服务、技术、管理和研究）以及HSRPROJ（正在进行的卫生服务研究项目），并人工检索了重症监护全国科学会议的摘要汇编（1994年1月1日至2001年12月31日）。
我们选择了针对危重症成人或儿童的随机和观察性对照试验。研究考察了ICU主治医生的人员配备策略以及医院和ICU死亡率及住院时间（LOS）等结局。研究由2名评审员进行选择和评判。我们审阅了2590篇摘要，确定了26项相关观察性研究（其中1项包含2组对照），从而得到27组替代人员配备策略的对照。20项研究聚焦于单个ICU。
我们将ICU医师配备分为低强度（无重症医学专家或选择性重症医学专家会诊）或高强度（强制性重症医学专家会诊或封闭式ICU [所有护理由重症医学专家指导]）组。在17项研究中的16项（94%）中，高强度人员配备与较低的医院死亡率相关，医院死亡率相对风险的合并估计值为0.71（95%置信区间[CI]，0.62 - 0.82）。在15项研究中的14项（93%）中，高强度人员配备与较低的ICU死亡率相关，ICU死亡率相对风险的合并估计值为0.61（95% CI，0.50 - 0.75）。在未经病例组合调整的13项研究中的10项中，高强度人员配备缩短了医院住院时间，在18项研究中的14项中缩短了ICU住院时间。在经病例组合调整的4项研究中的2项中，高强度人员配备与缩短医院住院时间相关，在两项研究中均与缩短ICU住院时间相关。病例组合调整后，没有研究发现高强度人员配备会导致住院时间延长。
与低强度相比，高强度的ICU医师配备与降低医院和ICU死亡率以及缩短医院和ICU住院时间相关。
