非医师人员配备对医疗 ICU 结局的影响。

Impact of nonphysician staffing on outcomes in a medical ICU.

机构信息

Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Medical Center, New York Presbyterian Hospital-Columbia, New York, NY.

Department of Anesthesia, New York Presbyterian Hospital-Columbia, New York, NY.

出版信息

Chest. 2011 Jun;139(6):1347-1353. doi: 10.1378/chest.10-2648. Epub 2011 Mar 10.

DOI:10.1378/chest.10-2648

PMID:21393397

Abstract

BACKGROUND

As the number of ICU beds and demand for intensivists increase, alternative solutions are needed to provide coverage for critically ill patients. The impact of different staffing models on the outcomes of patients in the medical ICU (MICU) remains unknown. In our study, we compare outcomes of nonphysician provider-based teams to those of medical house staff-based teams in the MICU.

METHODS

We conducted a retrospective review of 590 daytime (7:00 am-7:00 pm) admissions to two MICUs at one hospital. In one MICU staffed by nurse practitioners and physician assistants (MICU-NP/PA) there were nonphysicians (nurse practitioners and physicians assistants) during the day (7:00 am-7:00 pm) with attending physician coverage overnight. In the other MICU, there were medicine residents (MICU-RES) (24 h/d). The outcomes investigated were hospital mortality, length of stay (LOS) (ICU, hospital), and posthospital discharge destination.

RESULTS

Three hundred two patients were admitted to the MICU-NP/PA and 288 to the MICU-RES. Mortality probability model III (MPM(0)-III) predicted mortality was similar (P = .14). There was no significant difference in hospital mortality (32.1% for MICU-NP/PA vs 32.3% for MICU-RES, P = .96), MICU LOS (4.22 ± 2.51 days for MICU-NP/PA vs 4.44 ± 3.10 days for MICU-RES, P = .59), or hospital LOS (14.01 ± 2.92 days for MICU-NP/PA vs 13.74 ± 2.94 days for MICU-RES, P = .86). Discharge to a skilled care facility (vs home) was similar (37.1% for MICU-NP/PA vs 32.5% for MICU-RES, P = .34). After multivariate adjustment, MICU staffing type was not associated with hospital mortality (P = .26), MICU LOS (P = .29), hospital LOS (P = .19), or posthospital discharge destination (P = .90).

CONCLUSIONS

Staffing models including daytime use of nonphysician providers appear to be a safe and effective alternative to the traditional house staff-based team in a high-acuity, adult ICU.

摘要

背景

随着 ICU 床位和对重症监护医师需求的增加，需要寻找替代方案来为重症患者提供服务。不同人员配备模式对内科重症监护病房（MICU）患者结局的影响尚不清楚。在本研究中，我们比较了基于非医师提供者的团队和基于内科住院医师的团队在 MICU 中的结局。

方法

我们对一家医院的两个 MICU 中的 590 例日间（上午 7:00 至下午 7:00）入院患者进行了回顾性分析。一个 MICU 由执业护士和医师助理（MICU-NP/PA）配备人员，白天（上午 7:00 至下午 7:00）有非医师人员（执业护士和医师助理），夜间有主治医生提供覆盖。另一个 MICU 配备有内科住院医师（MICU-RES）（24 小时/天）。我们研究的结局包括医院死亡率、住院时间（ICU、医院）和出院后去向。

结果

302 例患者入住 MICU-NP/PA，288 例患者入住 MICU-RES。死亡率概率模型 III（MPM(0)-III）预测死亡率相似（P =.14）。医院死亡率无显著差异（MICU-NP/PA 组为 32.1%，MICU-RES 组为 32.3%，P =.96），MICU 住院时间（MICU-NP/PA 组为 4.22 ± 2.51 天，MICU-RES 组为 4.44 ± 3.10 天，P =.59）或医院住院时间（MICU-NP/PA 组为 14.01 ± 2.92 天，MICU-RES 组为 13.74 ± 2.94 天，P =.86）也无显著差异。出院至康复护理机构（而非家庭）的比例相似（MICU-NP/PA 组为 37.1%，MICU-RES 组为 32.5%，P =.34）。多变量调整后，MICU 人员配备类型与医院死亡率（P =.26）、MICU 住院时间（P =.29）、医院住院时间（P =.19）或出院后去向（P =.90）均无关。