Dale Christopher R, Hayden Shailaja J, Treggiari Miriam M, Curtis J Randall, Seymour Christopher W, Yanez N David, Fan Vincent S
Crit Care. 2012 Jun 18;16(3):R106. doi: 10.1186/cc11390.
Protocols for the delivery of analgesia, sedation and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniformly used. The extent to which elements of analgesia, sedation and delirium guidelines are incorporated into order sets at hospitals across a geographic area is not known. We hypothesized that both greater hospital volume and membership in a hospital network are associated with greater adherence of order sets to sedation guidelines.
Sedation order sets from all nonfederal hospitals without pediatric designation in Washington State that provided ongoing care to mechanically ventilated patients were collected and their content systematically abstracted. Hospital data were collected from Washington State sources and interviews with ICU leadership in each hospital. An expert-validated score of order set quality was created based on the 2002 four-society guidelines. Clustered multivariable linear regression was used to assess the relationship between hospital characteristics and the order set quality score.
Fifty-one Washington State hospitals met the inclusion criteria and all provided order sets. Based on expert consensus, 21 elements were included in the analgesia, sedation and delirium order set quality score. Each element was equally weighted and contributed one point to the score. Hospital order set quality scores ranged from 0 to 19 (median = 8, interquartile range 6 to 14). In multivariable analysis, a greater number of acute care days (P = 0.01) and membership in a larger hospital network (P = 0.01) were independently associated with a greater quality score.
Hospital volume and membership in a larger hospital network were independently associated with a higher quality score for ICU analgesia, sedation and delirium order sets. Further research is needed to determine whether greater order-set quality is associated with improved outcomes in the critically ill. The development of critical care networks might be one strategy to improve order set quality scores.
为重症机械通气患者提供镇痛、镇静和谵妄护理的方案已被证明可改善预后，但并未得到统一应用。镇痛、镇静和谵妄指南中的各项要素在一个地理区域内各医院的医嘱集里的纳入程度尚不清楚。我们假设，医院规模越大以及属于医院网络成员与医嘱集对镇静指南的更高依从性相关。
收集了华盛顿州所有未指定为儿科且为机械通气患者提供持续护理的非联邦医院的镇静医嘱集，并对其内容进行系统提取。医院数据来自华盛顿州的资料来源，并对每家医院的重症监护病房负责人进行了访谈。基于2002年四个学会的指南创建了一个经专家验证的医嘱集质量评分。采用聚类多变量线性回归来评估医院特征与医嘱集质量评分之间的关系。
华盛顿州的51家医院符合纳入标准，且均提供了医嘱集。根据专家共识，镇痛、镇静和谵妄医嘱集质量评分纳入了21项要素。每个要素权重相等，对评分贡献1分。医院医嘱集质量评分范围为0至19分（中位数 = 8分，四分位间距为6至14分）。在多变量分析中，更多的急性护理天数（P = 0.01）以及属于更大的医院网络（P = 0.01）与更高的质量评分独立相关。
医院规模以及属于更大的医院网络与重症监护病房镇痛、镇静和谵妄医嘱集的更高质量评分独立相关。需要进一步研究以确定更高的医嘱集质量是否与重症患者预后改善相关。发展重症监护网络可能是提高医嘱集质量评分的一种策略。
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