强化治疗医师主导的多学科扩展快速反应团队对全院心肺骤停和死亡率的影响。

Impact of an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality.

机构信息

Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

出版信息

Crit Care Med. 2013 Feb;41(2):506-17. doi: 10.1097/CCM.0b013e318271440b.

DOI:10.1097/CCM.0b013e318271440b

PMID:23263618

Abstract

OBJECTIVE

The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality.

DESIGN

This was a pre-post rapid response team implementation study.

SETTING

: Tertiary care academic center in Saudi Arabia.

PATIENTS

A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated.

INTERVENTION

The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53-0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85-0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78-0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95-3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74-0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66-0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72-0.99; p = 0.04).

CONCLUSION

The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.

摘要

目的

快速反应团队的有效性仍存在争议。然而，许多研究的快速反应团队都不是由重症监护医生领导的，其参与范围仅限于最初的激活，并且没有提供 ICU 后的随访。本研究的目的是研究实施由重症监护医生领导的多学科扩展快速反应团队对全院心肺骤停和死亡率的影响。

设计

这是一项快速反应团队实施前后的研究。

地点

沙特阿拉伯的一家三级保健学术中心。

患者

在快速反应团队实施前的 2 年共评估了 98391 例患者，在快速反应团队实施后的 3 年共评估了 157804 例患者。

干预措施

快速反应团队由任何医护人员根据预定义的标准激活，一个由四名重症监护医生领导的多学科快速反应团队做出反应，提供必要的管理和处置。快速反应团队的功能扩展到提供临床稳定前的随访。此外，快速反应团队提供强制性的 ICU 后随访至少 48 小时。

测量和主要结果

主要结果是心肺骤停和死亡率。快速反应团队实施后，非 ICU 心肺骤停从每 1000 例住院患者 1.4 例降至 0.9 例（相对风险，0.68；95%置信区间，0.53-0.86；p = 0.001），全院总死亡率从每 1000 例住院患者 22.5 例降至 20.2 例（相对风险，0.90；95%置信区间，0.85-0.95；p < 0.0001）。对于需要入住 ICU 的患者，快速反应团队实施后急性生理学和慢性健康评估 II 评分从 29.3 ± 9.3 降至 26.9 ± 8.5（p < 0.0001），医院死亡率从 57.4%降至 48.7%（相对风险，0.85；95%置信区间，0.78-0.92；p < 0.0001）。从病房转 ICU 的患者的不复苏医嘱从每 1000 例住院患者 0.7 例增加到 1.7 例（相对风险，2.58；95%置信区间，1.95-3.42；p < 0.0001），而从病房转 ICU 的患者的比例从 30.5%降至 26.1%（相对风险，0.86；95%置信区间，0.74-0.99；p = 0.03）。此外，ICU 再入院率从每 100 例 ICU 存活出院患者 18.6 例降至 14.3 例（相对风险，0.77；95%置信区间，0.66-0.89；p < 0.0001），ICU 后出院患者的死亡率从 18.2%降至 14.8%（相对风险，0.85；95%置信区间，0.72-0.99；p = 0.04）。