Division of Pulmonary Critical Care, and Sleep Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, USA.
Crit Care Med. 2012 Jul;40(7):2009-15. doi: 10.1097/CCM.0b013e31824e9eae.
Intensive care unit beds are limited, yet few guidelines exist for triage of patients to the intensive care unit, especially patients at low risk for mortality. The frequency with which low-risk patients are admitted to intensive care units in different hospitals is unknown. Our objective was to assess variation in the use of intensive care for patients with diabetic ketoacidosis, a common condition with a low risk of mortality.
Observational study using the New York State In-patient Database (2005-2007).
One hundred fifty-nine New York State acute care hospitals.
Fifteen thousand nine hundred ninety-four adult (≥ 18) hospital admissions with a primary diagnosis of diabetic ketoacidosis (International Classification of Diseases, Ninth Revision, Clinical Modification 250.1x).
None.
We calculated reliability- and risk-adjusted intensive care unit utilization, hospital length of stay, and mortality. We identified hospital-level factors associated with increased likelihood of intensive care unit admission after controlling patient characteristics using multilevel, mixed-effects logistic regression analyses; we assessed the amount of residual variation in intensive care unit utilization using the intraclass correlation coefficient. Use of intensive care for diabetic ketoacidosis patients varied widely across hospitals (adjusted range: 2.1% to 87.7%), but was not associated with hospital length of stay or mortality. After multilevel adjustment, hospitals with a high volume of diabetic ketoacidosis admissions admitted diabetic ketoacidosis patients to the intensive care unit less often (odds ratio 0.40, p = .002, highest quintile compared to lowest), whereas hospitals with higher rates of intensive care unit utilization for all nondiabetic ketoacidosis in-patients admitted diabetic ketoacidosis patients to the intensive care unit more frequently (odds ratio 1.31, p = .001, for each additional 10% increase). In the multilevel model, more than half (58%) of the variation in the intensive care unit admission practice attributable to hospitals remained unexplained.
We observed variations across hospitals in the use of intensive care for diabetic ketoacidosis patients that was not associated with differences in-hospital length of stay or mortality. Institutional practice patterns appear to impact admission decisions and represent a potential target for reduction of resource utilization in higher use institutions.
重症监护病房床位有限，但对于重症监护病房患者的分诊，尤其是对于低死亡率风险患者的分诊，几乎没有指南。不同医院低风险患者入住重症监护病房的频率尚不清楚。我们的目的是评估糖尿病酮症酸中毒患者使用重症监护的差异，这是一种死亡率低的常见疾病。
利用纽约州住院患者数据库（2005-2007 年）进行的观察性研究。
159 家纽约州急性护理医院。
15994 名患有原发性糖尿病酮症酸中毒（国际疾病分类，第九修订版，临床修正 250.1x）的成年（≥18 岁）住院患者。
无。
我们计算了可靠性和风险调整后的重症监护病房使用率、住院时间和死亡率。我们确定了与患者特征控制后，增加重症监护病房入院可能性相关的医院水平因素，使用多层次混合效应逻辑回归分析；我们使用组内相关系数评估重症监护病房使用的剩余变异量。不同医院的糖尿病酮症酸中毒患者使用重症监护的情况差异很大（调整范围：2.1%至 87.7%），但与住院时间或死亡率无关。经过多层次调整，糖尿病酮症酸中毒患者入院量较高的医院将糖尿病酮症酸中毒患者送入重症监护病房的可能性较低（比值比 0.40，p =.002，最高五分位组与最低五分位组相比），而对于所有非糖尿病酮症酸中毒住院患者重症监护使用率较高的医院，将糖尿病酮症酸中毒患者送入重症监护病房的可能性更高（比值比 1.31，p =.001，每增加 10%）。在多层次模型中，医院间差异的 58%以上（58%）无法解释。
我们观察到不同医院在使用重症监护治疗糖尿病酮症酸中毒患者方面存在差异，但与住院时间或死亡率无差异。机构实践模式似乎会影响入院决策，是降低高使用率机构资源利用的潜在目标。
