Studdert David M, Burns Jeffrey P, Mello Michelle M, Puopolo Ann Louise, Truog Robert D, Brennan Troyen A
Harvard School of Public Health, Boston, MA 02115, USA.
Pediatrics. 2003 Sep;112(3 Pt 1):553-8. doi: 10.1542/peds.112.3.553.
To determine the frequency, types, sources, and predictors of conflict surrounding the care of pediatric intensive care unit (PICU) patients with prolonged stay.
A tertiary care, university-affiliated PICU in Boston.
All patients admitted over an 11-month period whose stay exceeded 8 days (the 85th percentile length of stay for the PICU under study), and intensive care physicians and nurses who were responsible for their care.
We prospectively identified conflicts by interviewing the treating physicians and nurses at 2 stages during the patients' PICU stay. All conflicts detected were classified by type (team-family, intrateam, or intrafamily) and source. Using a case-control design, we then identified predictors of conflict through bivariate and multivariate analyses.
We enrolled 110 patients based on the length-of-stay criterion. Clinicians identified 55 conflicts involving 51 patients in this group. Hence, nearly one half of all patients followed had a conflict associated with their care. Thirty-three of the conflicts (60%) were team-family, 21 (38%) were intrateam, and the remaining 1 was intrafamily. The most commonly cited sources of team-family conflict were poor communication (48%), unavailability of parents (39%), and disagreements over the care plan (39%). Medicaid insurance status was independently associated with the occurrence of conflict generally (odds ratio = 4.97) and team-family conflict specifically (odds ratio = 7.83).
Efforts to reduce and manage conflicts that arise in the care of critically ill children should be sensitive to the distinctive features of these conflicts. Knowledge of risk factors for conflict may also help to target such interventions at the patients and families who need them most.
确定延长住院时间的儿科重症监护病房（PICU）患者护理过程中冲突的发生频率、类型、来源及预测因素。
波士顿一家大学附属的三级医疗PICU。
在11个月期间入院且住院时间超过8天（所研究PICU住院时间的第85百分位数）的所有患者，以及负责其护理的重症监护医生和护士。
我们在患者PICU住院期间的两个阶段通过采访主治医生和护士前瞻性地识别冲突。所有检测到的冲突按类型（团队-家庭、团队内部或家庭内部）和来源进行分类。然后采用病例对照设计，通过双变量和多变量分析确定冲突的预测因素。
根据住院时间标准，我们纳入了110名患者。临床医生在该组中识别出55起涉及51名患者的冲突。因此，几乎一半的随访患者在护理过程中存在冲突。其中33起冲突（60%）为团队-家庭冲突，21起（38%）为团队内部冲突，其余1起为家庭内部冲突。团队-家庭冲突最常被提及的来源是沟通不畅（48%）、家长无法到场（39%）以及护理计划分歧（39%）。医疗补助保险状态总体上与冲突的发生独立相关（优势比=4.97），特别是与团队-家庭冲突相关（优势比=7.83）。
减少和管理重症患儿护理过程中出现的冲突的努力应考虑到这些冲突的独特特征。了解冲突的风险因素也可能有助于针对最需要的患者和家庭进行此类干预。
