Department of Surgery, Beth Israel Medical Center, New York, NY, USA.
J Trauma Acute Care Surg. 2012 Jul;73(1):202-8. doi: 10.1097/TA.0b013e31824ba4bf.
Most surgical critical care literature reflects practices at trauma centers and tertiary hospitals. Surgical critical care needs and practices may be quite different at nontrauma center teaching hospitals. As acute care surgery develops as a component of surgical critical care and trauma, the opportunities and challenges of the nontrauma centers should be considered.
In 2001, a new surgical critical care service was created for an 800-bed urban teaching hospital with a 12-bed surgical intensive care unit (SICU). Consults, daily rounds, daily notes, and adherence to best practices were standardized over the next 9 years for a team of postgraduate year-1 and -2 surgical residents, physician assistants and surgical intensivists. The Fundamentals of Critical Care Support course was given as basic introduction, and published guidelines for ventilators, hemodynamics, cardiac, infections, and nutrition management were implemented. A "beyond FCCS" curriculum was repeated every resident rotation. A 12-bed stepdown unit was developed for the more stable patients, mostly run by SICU physician assistants with SICU attending coverage. The first 5 years, night coverage was by the daytime intensivist from home. The last 4 years, night coverage was in-unit surgical intensivists or cardiac surgeons.
Data for 13,020 patients drawn from 152,154 operations over 9 years is reported. Surgery grew 89% to 24,000 cases/year in 2010. Half the patients were general, gastrointestinal oncology, or vascular surgery. Ninety-two percent were perioperative. The 8% nonoperative patients were mostly gastrointestinal bleeding, abdominal pain, or pancreatitis. In the first year, annual SICU mortality decreased from an average of 4.5% the 5 previous years to 1.96% (2002) and remained 1.75% (2003), 2.1% (2004), 1.9% (2005), 1.5% (2006), 1.5% (2007), 2.2% (2008), 2.4% (2009), and 2.1% (2010).
Annual mortality immediately improved at a busy nontrauma hospital with rapid, structured consultation by the SICU team, comprehensive daily rounds guided by critical care best practices, and daytime in-unit surgical intensivists. Low mortality was maintained over 9 years as surgery volume nearly doubled but did not improve further with 24/7 in-unit coverage by surgical intensivists and cardiac surgeons. The process of care in an SICU may be more important than 24 hour a day, 7 days a week intensivists.
Therapeutic study, level II.
大多数外科重症监护文献反映了创伤中心和三级医院的实践。非创伤中心教学医院的外科重症监护需求和实践可能大不相同。随着急性外科手术作为外科重症监护和创伤的一个组成部分的发展，应该考虑非创伤中心的机会和挑战。
2001 年，在一家拥有 800 张床位的城市教学医院和 12 张外科重症监护病房（SICU）的情况下，创建了一个新的外科重症监护服务。在接下来的 9 年里，对住院医师 1 年级和 2 年级的外科住院医师、医师助理和外科重症监护医师团队进行了咨询、每日查房、每日记录和遵守最佳实践的标准化。为基础重症监护支持课程提供了基本介绍，并实施了呼吸机、血液动力学、心脏、感染和营养管理的出版指南。每一轮住院医师都会重复“超越 FCCS”课程。为了更稳定的患者，开发了一个 12 张床位的过渡病房，主要由 SICU 医师助理和 SICU 主治医生覆盖。前 5 年，夜间由白天的重症监护医生从家里负责。在过去的 4 年里，夜间由重症监护病房的外科医生或心脏外科医生负责。
报告了 9 年来从 152154 例手术中抽取的 13020 例患者的数据。2010 年，手术量增长了 89%，达到 24000 例/年。一半的患者是普通外科、胃肠肿瘤或血管外科患者。92%是围手术期患者。非手术患者中，8%的患者主要是胃肠道出血、腹痛或胰腺炎。在第一年，重症监护病房的年度死亡率从前 5 年的平均 4.5%降至 1.96%（2002 年），并保持在 1.75%（2003 年）、2.1%（2004 年）、1.9%（2005 年）、1.5%（2006 年）、1.5%（2007 年）、2.2%（2008 年）、2.4%（2009 年）和 2.1%（2010 年）。
在一家繁忙的非创伤医院，通过 SICU 团队的快速、结构化咨询，根据重症监护最佳实践进行全面的每日查房，以及白天在重症监护病房的外科医生，重症监护病房的年度死亡率立即得到改善。随着手术量几乎翻了一番，9 年来低死亡率保持不变，但随着重症监护病房的外科医生和心脏外科医生 24/7 的全覆盖，死亡率并没有进一步改善。SICU 的治疗过程可能比 24 小时/天、7 天/周的重症监护医生更重要。
治疗研究，II 级。
