Chittawatanarat Kaweesak, Pamorsinlapathum Thiti
Division of Surgical Critical Care and Trauma, Department of Surgery, Faculty of Medikine, Chiang Mai University, Chiang Mai 50200, Thailand.
J Med Assoc Thai. 2009 Dec;92(12):1627-34.
A closed model oflCU (intensive care unit) care is associated with improved outcomes and less resource utilization in mixed medical and surgical ICUs as well as traumatic ICUs. However most of ICUs in developing countries use an opened model especially in surgical ICUs due to lack of specialized physician. The aims of the present are to compare the effects of closed and opened model on ICU mortality and length of ICU stay.
The authors conducted a retrospective study to compare mortality between two periods of time. First period was between July 2002 and June 2004, and used open model. The second period was between July 2004 and June 2006, and followed by closed model. The closed model was defined as an ICU service led and managed by an intensivist. The open model was an ICU service where critically ill surgical patients were managed by host surgeons individually.
Two thousand two hundred and sixty nine patients were included in the present (Open vs. Close, 1038 vs. 1231). The overall ICU mortality rate was decreased with statistical significance in closed model (27.4% vs. 23.4%; p = 0.03). This effect was obvious in patients admitted to ICU longer than 48 hours (22.7% vs. 13.9%; p < 0.01). After adjusting for differences in baseline characteristics and case-mix factor, the risk of death in closed ICU model was also statistically significant less than opened model [RR = 0.85 (0.74-0.98); p = 0.02]. The effect was explicit in patients admitted to ICUlonger than 48 hours [RR = 0.60 (0.47-0. 76); p < 0.01]. However, risk of death in non-traumatic patients and elderly patients older than 65 years of age tend to be lower in closed model [RR = 0.81 (0.64-1.01); p = 0.06 and RR = 0.81 (0.64-1.01); p = 0.07 respectively]. In addition, closed model ICU has shorter length of ICU stay (5.4 +/- 7.1 vs. 4.6 +/- 6.1 days; p < 0.01) and adjusted length of ICU stay was lowered about 0.80 day [-0.80 day (-1.34 to -0.25); p < 0.01] in closed model with statistical significance when compare to open model.
The closed model, led and managed by an intensivist, is associated with reduction in overall ICU mortality and has greatest effect in patients admitted longer than 48 hours. Furthermore, this model shortens ICU length ofstay
在综合内科和外科重症监护病房以及创伤重症监护病房中，封闭式重症监护病房（ICU）护理模式与改善预后及减少资源利用相关。然而，由于缺乏专科医生，发展中国家的大多数重症监护病房采用开放式模式，尤其是在外科重症监护病房。本研究的目的是比较封闭式和开放式模式对ICU死亡率和ICU住院时间的影响。
作者进行了一项回顾性研究，比较两个时间段的死亡率。第一个时间段是2002年7月至2004年6月，采用开放式模式。第二个时间段是2004年7月至2006年6月，采用封闭式模式。封闭式模式定义为由一名重症医学专家领导和管理的ICU服务。开放式模式是指危重症外科患者由主管外科医生单独管理的ICU服务。
本研究共纳入2269例患者（开放式与封闭式，分别为1038例和1231例）。封闭式模式下的总体ICU死亡率有统计学意义的降低（27.4%对23.4%；p = 0.03）。这种效应在入住ICU超过48小时的患者中很明显（22.7%对13.9%；p < 0.01）。在调整基线特征和病例组合因素的差异后，封闭式ICU模式下的死亡风险也显著低于开放式模式[相对危险度（RR）= 0.85（0.74 - 0.98）；p = 0.02]。这种效应在入住ICU超过48小时的患者中很明显[RR = 0.60（0.47 - 0.76）；p < 0.01]。然而，在非创伤性患者和65岁以上老年患者中，封闭式模式下的死亡风险往往较低[RR分别为0.81（0.64 - 1.01）；p = 0.06和RR = 0.81（0.64 - 1.01）；p = 0.07]。此外，封闭式模式的ICU住院时间更短（5.4±7.1天对4.6±6.1天；p < 0.01），与开放式模式相比，封闭式模式下调整后的ICU住院时间降低了约0.80天[-0.80天（-1.34至-0.25）；p < 0.01]，具有统计学意义。
由重症医学专家领导和管理的封闭式模式与总体ICU死亡率降低相关，对入住超过48小时的患者效果最为显著。此外，这种模式缩短了ICU住院时间
