Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Università degli Studi di Milano-U.O. Anestesia e Rianimazione, Azienda Ospedaliera Polo Universitario San Paolo, via A. Di Rudinì 8, 20142, Milan, Italy.
Department of Anaesthesia, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
Intensive Care Med. 2010 Oct;36(10):1772-1779. doi: 10.1007/s00134-010-1933-2. Epub 2010 Jun 9.
To identify factors influencing triage decisions and investigate whether admission to the intensive care unit (ICU) could reduce mortality compared with treatment on the ward.
A multicentre cohort study in 11 university hospitals from seven countries, evaluating triage decisions and outcomes of patients referred for admission to ICU who were either accepted, or refused and treated on the ward. Confounding in the estimation of the effect of ICU admission on mortality was controlled by use of a propensity score approach, which adjusted for the probability of being admitted. Variability across centres was accounted for in both analyses of factors influencing ICU admission and effect of ICU admission on mortality.
Eligible were 8,616 triages in 7,877 patients referred for ICU admission. Variables positively associated with probability of being admitted to ICU included: ventilators in ward; bed availability; Karnofsky score; absence of comorbidity; presence of haematological malignancy; emergency surgery and elective surgery (versus medical treatment); trauma, vascular involvement, liver involvement; acute physiologic score II; ICU treatment (versus ICU observation). Multiple triages during patient's hospital stay and age were negatively associated with ICU admission. The area under the receiver operating characteristic (ROC) curve of the model was 0.83 [95% confidence interval (CI): 0.81-0.84], with Hosmer-Lemeshow test P = 0.300. ICU admission was associated with a statistically significant reduction of both 28-day mortality [odds ratio (OR): 0.73; 95% CI: 0.62-0.87] and 90-day mortality (0.79; 0.66-0.93). The benefit of ICU admission increased substantially in patients with greater severity of illness.
We suggest that intensivists take great care to avoid ICU admission of patients judged not severe enough for ICU or with low performance status, and they tend to admit surgical patients more readily than medical patients. Interestingly, they do not judge age per se as a reason for refusal of ICU admission. Admission to ICU was associated with a reduction of both 28- and 90-day mortality, particularly in patients with greater severity of illness at time of triage.
确定影响分诊决策的因素，并调查与在病房治疗相比，入住重症监护病房（ICU）是否能降低死亡率。
这是一项在 7 个国家的 11 所大学医院进行的多中心队列研究，评估了被转至 ICU 并接受收治、或被拒绝收治而在病房治疗的患者的分诊决策和结局。通过使用倾向评分法来控制 ICU 收治对死亡率影响的混杂因素，该方法调整了收治的可能性。在 ICU 收治对死亡率的影响分析中，以及在影响 ICU 收治的因素分析中，均考虑了中心间的变异性。
共纳入 7877 名患者的 8616 次分诊，这些患者被转至 ICU 治疗。与收治至 ICU 的可能性呈正相关的变量包括：病房中的呼吸机、床位可用性、卡诺夫斯基评分、无合并症、血液系统恶性肿瘤、急诊手术和择期手术（而非内科治疗）、创伤、血管受累、肝脏受累、急性生理学评分 II、ICU 治疗（而非 ICU 观察）。患者住院期间多次分诊和年龄与 ICU 收治呈负相关。该模型的受试者工作特征（ROC）曲线下面积为 0.83[95%置信区间（CI）：0.81-0.84]，Hosmer-Lemeshow 检验 P = 0.300。ICU 收治与 28 天死亡率（比值比[OR]：0.73；95%CI：0.62-0.87）和 90 天死亡率（0.79；95%CI：0.66-0.93）的统计学显著降低均相关。在病情更严重的患者中，ICU 收治的获益显著增加。
我们建议，重症监护医生在决定是否将病情不够严重或一般状况不佳的患者收入 ICU 时要格外慎重，并倾向于更容易收治外科患者而不是内科患者。有趣的是，他们并不将年龄本身视为拒绝 ICU 收治的原因。入住 ICU 与 28 天和 90 天死亡率的降低相关，尤其是在分诊时病情更严重的患者中。
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