Martin D K, Singer P A, Bernstein M
Department of Health Policy, Management and Evaluation, University of Toronto, Canada.
J Neurol Neurosurg Psychiatry. 2003 Sep;74(9):1299-303. doi: 10.1136/jnnp.74.9.1299.
The purpose of this study was to describe the process used to decide which patients are admitted to the intensive care unit (ICU) at a hospital with special focus on access for neurosurgery patients, and evaluate it using "accountability for reasonableness".
Qualitative case study methodology was used. Data were collected from documents, interviews with key informants, and observations. The data were subjected to thematic analysis and evaluated using the four conditions of "accountability for reasonableness" (relevance, publicity, appeals, enforcement) to identify good practices and opportunities for improvement.
ICU admissions were based on the referring physician's assessment of the medical need of the patient for an ICU bed. Non-medical criteria (for example, family wishes) also influenced admission decisions. Although there was an ICU bed allocation policy, patient need always superceded the bed allocation policy. ICU admission guidelines were not used. Admission decisions and reasons were disseminated to the ICU charge nurse, the bed coordinator, the ICU resident, the intensivist, and the requesting physician/surgeon by word of mouth and by written documentation in the patient's chart, but not to the patient or family. Appeals occurred informally, through negotiations between clinicians. Enforcement of relevance, publicity, and appeals was felt to be either non-existent or deficient.
Conducting a case study of priority setting decisions for patients requiring ICU beds, with a special focus on neurosurgical patients, and applying the ethical framework "accountability for reasonableness" can help critical care units improve the fairness of their priority setting.
本研究旨在描述一家医院决定哪些患者入住重症监护病房（ICU）的过程，特别关注神经外科患者的准入情况，并使用“合理性问责制”对其进行评估。
采用定性案例研究方法。数据收集自文件、对关键信息提供者的访谈以及观察。对数据进行主题分析，并使用“合理性问责制”的四个条件（相关性、公开性、申诉、执行）进行评估，以确定良好做法和改进机会。
ICU的收治基于转诊医生对患者对ICU床位的医疗需求评估。非医疗标准（如家属意愿）也会影响收治决定。尽管有ICU床位分配政策，但患者需求始终优先于床位分配政策。未使用ICU收治指南。收治决定和理由通过口头以及患者病历中的书面文件传达给ICU责任护士、床位协调员、ICU住院医师、重症监护医生以及申请的内科医生/外科医生，但未告知患者或家属。申诉通过临床医生之间的协商非正式地进行。相关性、公开性和申诉的执行被认为不存在或不足。
对需要ICU床位患者的优先排序决策进行案例研究，特别关注神经外科患者，并应用“合理性问责制”的伦理框架，有助于重症监护病房提高其优先排序的公平性。
