Cooke Colin R, Watkins Timothy R, Kahn Jeremy M, Treggiari Miriam M, Caldwell Ellen, Hudson Leonard D, Rubenfeld Gordon D
Division of Pulmonary & Critical Care Medicine, University of Washington School of Medicine, Harborview Medical Center, 325 9th Avenue, Box 359762, Seattle, Washington, 98104, USA.
Crit Care. 2008;12(6):R134. doi: 10.1186/cc7105. Epub 2008 Nov 3.
Little is known about the mechanisms through which intensivist physician staffing influences patient outcomes. We aimed to assess the effect of closed-model intensive care on evidence-based ventilatory practice in patients with acute lung injury (ALI).
We conducted a secondary analysis of a prospective population-based cohort of 759 patients with ALI who were alive and ventilated on day three of ALI, and were cared for in 23 intensive care units (ICUs) in King County, Washington.
We compared day three tidal volume (VT) in open versus closed ICUs adjusting for potential patient and ICU confounders. In 13 closed model ICUs, 429 (63%) patients were cared for. Adjusted mean VT (mL/Kg predicted body weight (PBW) or measured body weight if height not recorded) for patients in closed ICUs was 1.40 mL/Kg PBW (95% confidence interval (CI) = 0.57 to 2.24 mL/Kg PBW) lower than patients in open model ICUs. Patients in closed ICUs were more likely (odds ratio (OR) = 2.23, 95% CI = 1.09 to 4.56) to receive lower VT (<or= 6.5 mL/Kg PBW) and were less likely (OR = 0.30, 95% CI = 0.17 to 0.55) to receive a potentially injurious VT (>or= 12 mL/Kg PBW) compared with patients cared for in open ICUs, independent of other covariates. The effect of closed ICUs on hospital mortality was not changed after accounting for delivered VT.
Patients with ALI cared for in closed model ICUs are more likely to receive lower VT and less likely to receive higher VT, but there were no other differences in measured processes of care. Moreover, the difference in delivered VT did not completely account for the improved mortality observed in closed model ICUs.
关于重症监护医师人员配备影响患者预后的机制，目前了解甚少。我们旨在评估封闭式重症监护模式对急性肺损伤（ALI）患者循证通气实践的影响。
我们对一组基于人群的前瞻性队列进行了二次分析，该队列包含759例ALI患者，这些患者在ALI第三天仍存活且接受机械通气，并在华盛顿州金县的23个重症监护病房（ICU）接受治疗。
我们比较了开放式与封闭式ICU中患者第三天的潮气量（VT），并对潜在的患者和ICU混杂因素进行了调整。在13个封闭式ICU中，有429例（63%）患者接受了治疗。封闭式ICU中患者的调整后平均VT（mL/千克预测体重（PBW），若未记录身高则为实测体重）比开放式ICU中的患者低1.40 mL/千克PBW（95%置信区间（CI）=0.57至2.24 mL/千克PBW）。与在开放式ICU接受治疗的患者相比，封闭式ICU中的患者更有可能（优势比（OR）=2.23，95%CI=1.09至4.56）接受较低的VT（≤6.5 mL/千克PBW），且不太可能（OR=0.30，95%CI=0.17至0.55）接受潜在有害的VT（≥12 mL/千克PBW），这与其他协变量无关。在考虑所输送的VT后，封闭式ICU对医院死亡率的影响并未改变。
在封闭式ICU接受治疗的ALI患者更有可能接受较低VT且不太可能接受较高VT，但在实测的护理过程中没有其他差异。此外，所输送VT的差异并未完全解释在封闭式ICU中观察到的死亡率改善情况。
