Division of Neurology, Department of Medicine, Cooper University Hospital, Robert Wood Johnson Medical School, UMDNJ, Camden, NJ 08103, USA.
J Crit Care. 2011 Dec;26(6):620-5. doi: 10.1016/j.jcrc.2011.02.009. Epub 2011 May 18.
Transfer of critically ill patients from outside emergency department has the potential for delaying the admission to the intensive care unit. We sought to determine the effect of outside emergency department transfer on hospital outcomes in critically ill patients with stroke.
We designed a retrospective cohort analysis using a prospectively compiled and maintained registry (Cerner Project IMPACT). Patients with acute ischemic stroke and intracerebral hemorrhage admitted to our intensive care unit from our emergency department and transfers from outside emergency department within 24 hours of stroke between January 1, 2003, and December 31, 2008, were selected for the analysis. Data collected included demographics, admission physiologic variables, Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation II score, and total intensive care unit and hospital length of stay. Primary (poor) outcome was a composite of death or fully dependent status at hospital discharge, and secondary outcomes were intensive care unit and hospital length of stay. To assess for the impact of outside emergency department transfer on primary and secondary outcomes, demographic and admission clinical variables were used to construct logistic regression models using the outcome measure as a dependent variable.
A total of 448 patients were selected for analysis. The mean age was 65 ± 14 years, of which 214 (48%) were male and 282 (65%) white, 152 (34%) were patients with acute ischemic stroke, and 296 (66%) were patients with intracerebral hemorrhage. The median hospital length of stay was 7 days (interquartile range, 4-11 days) and median intensive care unit length of stay was 2 days (interquartile range, 1-3 days). Overall hospital mortality was 30%, and outside emergency department transfer increased the odds of poor outcome by 2-fold (65% vs 34%; P = .05). Multivariate regression analysis showed that age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.01-1.1), Acute Physiology and Chronic Health Evaluation II score >14 (OR, 1.9; 95% CI, 1.3-2.7), Glasgow Coma Scale <12 (OR, 2.0; 95% CI, 1.4-2.8), do-not-resuscitate status (OR, 3.5; 95% CI, 2.2-5.9), and outside emergency department transfers (OR, 1.4; 95% CI, 1.02-1.8) were independently associated with poor outcome. Outside emergency department transfer was not significantly associated with secondary outcomes.
These data suggest that in critically ill patients with stroke, transfer from outside emergency department is independently associated with poor outcome at hospital discharge. Further research is needed as to identify the potential causes for this effect.
从急诊外转入的危重症患者有可能延迟入住重症监护病房。我们旨在确定在因卒中转入重症监护病房的危重症患者中，急诊外转入对其预后的影响。
我们采用前瞻性收集和维护的登记系统（Cerner Project IMPACT）进行回顾性队列分析。入选分析的患者为 2003 年 1 月 1 日至 2008 年 12 月 31 日期间从我院急诊室入院或从急诊外转入（发病后 24 小时内）的急性缺血性卒中和脑出血患者。收集的数据包括人口统计学资料、入院时的生理变量、格拉斯哥昏迷量表、急性生理学和慢性健康评估Ⅱ评分以及重症监护病房和医院的总住院时间。主要（不良）预后是出院时死亡或完全依赖状态的复合结局，次要预后是重症监护病房和医院的住院时间。为了评估急诊外转入对主要和次要结局的影响，我们使用逻辑回归模型，以结局为因变量，采用人口统计学和入院时临床变量来构建模型。
共入选 448 例患者。患者的平均年龄为 65±14 岁，其中 214 例（48%）为男性，282 例（65%）为白人，152 例（34%）为急性缺血性卒中患者，296 例（66%）为脑出血患者。中位医院住院时间为 7 天（四分位间距，4-11 天），中位重症监护病房住院时间为 2 天（四分位间距，1-3 天）。总体医院死亡率为 30%，急诊外转入使不良结局的可能性增加了 2 倍（65%比 34%；P=0.05）。多变量回归分析显示，年龄（比值比[OR]，1.02；95%置信区间[CI]，1.01-1.1）、急性生理学和慢性健康评估Ⅱ评分＞14（OR，1.9；95%CI，1.3-2.7）、格拉斯哥昏迷量表＜12（OR，2.0；95%CI，1.4-2.8）、不复苏状态（OR，3.5；95%CI，2.2-5.9）和急诊外转入（OR，1.4；95%CI，1.02-1.8）与不良结局独立相关。急诊外转入与次要结局无显著相关性。
这些数据表明，在因卒中转入重症监护病房的危重症患者中，从急诊外转入与出院时的不良预后独立相关。需要进一步研究以确定这种影响的潜在原因。
