Kumwilaisak Kanya, Noto Alberto, Schmidt Ulrich H, Beck Clare I, Crimi Claudia, Lewandrowski Kent, Bigatello Luca M
Department of Anesthesia and Critical Care, Critical Care Division, Massachusetts General Hospital, Boston, MA, USA.
Crit Care Med. 2008 Nov;36(11):2993-9. doi: 10.1097/CCM.0b013e31818b3a9d.
Diagnostic testing is frequently overused in the intensive care unit. We devised guidelines to optimize blood tests utilization, and designed this study to quantify their efficacy over time, their safety, and their possible benefits.
Laboratory testing guidelines were created by consensus and implemented through repeated staff education. The guidelines included: a) the tests to be obtained daily: complete blood count, serum electrolytes, urea nitrogen, creatinine, and blood glucose concentration; b) the need to discuss laboratory testing at daily patient's rounds; c) the need to provide a written order for all tests. The number of tests performed, corresponding physician orders, and various outcome measures were collected for two 6-month study periods, before and after the first day of implementation of the guidelines.
Twenty-bed surgical intensive care unit in a tertiary care teaching hospital.
All patients admitted during the two study periods.
Laboratory tests and related physician orders, demographics, blood products transfusion, and outcomes were collected from hospital databases. In prospectively defined subgroups, additional outcome measures were obtained by ad-hoc chart review.
One thousand one hundred seventeen patients were enrolled. After the institution of the guidelines, the number of laboratory tests decreased by 37% (from 64,305 to 40,877), and the number of respective physician orders increased by 38% (from 20,940 to 35,472), p < 0.001. These results were manifest within 1 month, sustained through the study period, and still present at 1 yr. No changes in outcomes or in the rates of selected complications were detected. Red blood cells utilization correlated linearly (r .47) with the number of blood tests performed in both study periods.
Guidelines designed to optimize laboratory tests use in an intensive care unit can produce rapid and long-lasting effects, can be safe, and may affect the number of red blood cell units transfused.
诊断检测在重症监护病房中经常被过度使用。我们制定了优化血液检测利用的指南，并设计了本研究以量化其随时间推移的效果、安全性及可能的益处。
通过共识制定实验室检测指南，并通过反复的员工培训来实施。指南包括：a）每日需进行的检测：全血细胞计数、血清电解质、尿素氮、肌酐和血糖浓度；b）在每日的患者查房中讨论实验室检测的必要性；c）所有检测都需要提供书面医嘱。在指南实施首日之前和之后的两个6个月研究期内，收集了所进行检测的数量、相应的医生医嘱以及各种结果指标。
一家三级护理教学医院的20张床位的外科重症监护病房。
两个研究期内收治的所有患者。
从医院数据库中收集实验室检测及相关医生医嘱、人口统计学数据、血液制品输注情况和结果。在前瞻性定义的亚组中，通过临时图表审查获得额外的结果指标。
共纳入1117例患者。指南实施后，实验室检测数量减少了37%（从64305次降至40877次），相应的医生医嘱数量增加了38%（从20940条增至35472条），p<0.001。这些结果在1个月内显现，在研究期间持续存在，且在1年后仍然存在。未检测到结果或选定并发症发生率的变化。在两个研究期内，红细胞的使用量与所进行的血液检测数量呈线性相关（r = 0.47）。
旨在优化重症监护病房实验室检测使用的指南可产生快速且持久的效果，可能是安全的，并且可能会影响红细胞输注单位的数量。
