Higgins Thomas L, McGee William T, Steingrub Jay S, Rapoport John, Lemeshow Stanley, Teres Daniel
Department of Medicine, Baystate Medical Center, Springfield, MA, USA.
Crit Care Med. 2003 Jan;31(1):45-51. doi: 10.1097/00003246-200301000-00007.
Scoring systems that predict mortality do not necessarily predict prolonged length of stay or costs in the intensive care unit (ICU). Knowledge of characteristics predicting prolonged ICU stay would be helpful, particularly if some factors could be modified. Such factors might include process of care, including active involvement of full-time ICU physicians and length of hospital stay before ICU admission.
Demographic data, clinical diagnosis at ICU admission, Simplified Acute Physiology Score, and organizational characteristics were examined by logistic regression for their effect on ICU and hospital length of stay and weighted hospital days (WHD), a proxy for high cost of care.
A total of 34 ICUs at 27 hospitals participating in Project IMPACT during 1998.
A total of 10,900 critically ill medical, surgical, and trauma patients qualifying for Simplified Acute Physiology Score assessment.
None.
Overall, 9.8% of patients had excess WHD, but the percentage varied by diagnosis. Factors predicting high WHD include Simplified Acute Physiology Score survival probability, age of 40 to 80 yrs, presence of infection or mechanical ventilation 24 hrs after admission, male sex, emergency surgery, trauma, presence of critical care fellows, and prolonged pre-ICU hospital stay. Mechanical ventilation at 24 hrs predicts high WHD across diagnostic categories, with a relative risk of between 2.4 and 12.9. Factors protecting against high WHD include do-not-resuscitate order at admission, presence of coma 24 hrs after admission, and active involvement of full-time ICU physicians.
Patients with high WHD, and thus high costs, can be identified early. Severity of illness only partially explains high WHD. Age is less important as a predictor of high WHD than presence of infection or ventilator dependency at 24 hrs. Both long ward stays before ICU admission and lack of full-time ICU physician involvement in care increase the probability of long ICU stays. These latter two factors are potentially modifiable and deserve prospective study.
预测死亡率的评分系统不一定能预测重症监护病房（ICU）的延长住院时间或费用。了解预测ICU延长住院时间的特征会有所帮助，特别是如果某些因素可以改变的话。这些因素可能包括护理过程，包括专职ICU医生的积极参与以及ICU入院前的住院时间。
通过逻辑回归分析人口统计学数据、ICU入院时的临床诊断、简化急性生理学评分和组织特征对ICU和医院住院时间以及加权住院天数（WHD，护理高成本的一个替代指标）的影响。
1998年期间参与“影响项目”的27家医院中的34个ICU。
共有10900名符合简化急性生理学评分评估标准的危重病医学、外科和创伤患者。
无。
总体而言，9.8%的患者有过高的WHD，但该百分比因诊断而异。预测高WHD的因素包括简化急性生理学评分生存概率、40至80岁的年龄、入院后24小时存在感染或机械通气、男性、急诊手术、创伤、有重症监护住院医师、以及ICU入院前住院时间延长。入院后24小时的机械通气在所有诊断类别中都预测高WHD，相对风险在2.4至12.9之间。防止高WHD的因素包括入院时的不复苏医嘱、入院后24小时存在昏迷以及专职ICU医生的积极参与。
可以早期识别出WHD高从而费用高的患者。疾病严重程度只能部分解释高WHD。作为高WHD的预测因素，年龄不如入院后24小时存在感染或呼吸机依赖重要。ICU入院前在病房的长时间停留以及缺乏专职ICU医生参与护理都会增加ICU长时间住院的可能性。后两个因素有可能改变，值得进行前瞻性研究。
