Carratalà Jordi, Garcia-Vidal Carolina, Ortega Lucía, Fernández-Sabé Núria, Clemente Mercedes, Albero Ginesa, López Marta, Castellsagué Xavier, Dorca Jordi, Verdaguer Ricard, Martínez-Montauti Joaquín, Manresa Frederic, Gudiol Francesc
Infectious Disease Service, Bellvitge Institute for Biomedical Research (IDIBELL)-Hospital Universitari de Bellvitge, University of Barcelona, L'Hospitalet, Barcelona, Spain.
Arch Intern Med. 2012 Jun 25;172(12):922-8. doi: 10.1001/archinternmed.2012.1690.
The length of hospital stay (LOS) for community-acquired pneumonia (CAP) varies considerably, even though this factor has a major impact on the cost of care. We aimed to determine whether the use of a 3-step critical pathway is safe and effective in reducing duration of intravenous antibiotic therapy and length of stay in hospitalized patients with CAP.
We randomly assigned 401 adults who required hospitalization for CAP to follow a 3-step critical pathway including early mobilization and use of objective criteria for switching to oral antibiotic therapy and for deciding on hospital discharge or usual care. The primary end point was LOS. Secondary end points were the duration of intravenous antibiotic therapy, adverse drug reactions, need for readmission, overall case-fatality rate, and patients' satisfaction.
Median LOS was 3.9 days in the 3-step group and 6.0 days in the usual care group (difference, -2.1 days; 95% CI, -2.7 to -1.7; P < .001). Median duration of intravenous antibiotic therapy was 2.0 days in the 3-step group and 4.0 days in the usual care group (difference, -2.0 days; 95% CI, -2.0 to -1.0; P < .001). More patients assigned to usual care experienced adverse drug reactions (4.5% vs 15.9% [difference, -11.4 percentage points; 95% CI, -17.2 to -5.6 percentage points; P < .001]). No significant differences were observed regarding subsequent readmissions, case fatality rate, and patients' satisfaction with care.
The use of a 3-step critical pathway was safe and effective in reducing the duration of intravenous antibiotic therapy and LOS for CAP and did not adversely affect patient outcomes. Such a strategy will help optimize the process of care of hospitalized patients with CAP, and hospital costs would be reduced.
isrctn.org Identifier: ISRCTN17875607.
社区获得性肺炎（CAP）患者的住院时间差异很大，尽管这一因素对护理成本有重大影响。我们旨在确定采用三步关键路径在缩短CAP住院患者静脉抗生素治疗时间和住院时间方面是否安全有效。
我们将401名因CAP需要住院治疗的成年人随机分为两组，一组遵循包括早期活动以及使用客观标准来切换至口服抗生素治疗和决定出院的三步关键路径，另一组接受常规治疗。主要终点是住院时间。次要终点包括静脉抗生素治疗时间、药物不良反应、再次入院需求、总体病死率以及患者满意度。
三步组的中位住院时间为3.9天，常规治疗组为6.0天（差异为-2.1天；95%置信区间为-2.7至-1.7；P<.001）。三步组静脉抗生素治疗的中位时间为2.0天，常规治疗组为4.0天（差异为-2.0天；95%置信区间为-2.0至-1.0；P<.001）。更多接受常规治疗的患者出现药物不良反应（4.5%对15.9%[差异为-11.4个百分点；95%置信区间为-17.2至-5.6个百分点；P<.001]）。在后续再次入院、病死率以及患者对护理的满意度方面未观察到显著差异。
采用三步关键路径在缩短CAP患者静脉抗生素治疗时间和住院时间方面安全有效，且未对患者预后产生不利影响。这样的策略将有助于优化CAP住院患者的护理流程，并降低医院成本。
isrctn.org标识符：ISRCTN17875607。
