危重症患者的知识转化干预措施：系统评价*。
Knowledge translation interventions for critically ill patients: a systematic review*.
机构信息
1Department of Critical Care Medicine, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 2Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. 3Department of Medicine, Queen's University, Kingston, ON, Canada. 4Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada. 5Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada. 6Department of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada. 7Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada. 8Institute of Public Health, University of Calgary, Calgary, AB, Canada. 9Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada. 10Department of Medicine, Providence Health Care and University of British Columbia, Vancouver, BC, Canada. 11Department of Medicine, McMaster University, Hamilton, ON, Canada. 12Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. 13Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 14Winnipeg Regional Health Authority, Winnipeg, MB, Canada. 15Department of Community Health and Epidemiology, Queen's University, Kingston, ON, Canada. 16Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. 17Department of Medicine, University of Toronto, Toronto, ON, Canada. 18Department of Critical Care Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada. 19Department of Medicine, University of Manitoba, Winnipeg, MB, Canada. 20Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
出版信息
Crit Care Med. 2013 Nov;41(11):2627-40. doi: 10.1097/CCM.0b013e3182982b03.
OBJECTIVE
We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care.
DATA SOURCES
We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews.
STUDY SELECTION
Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies.
DATA EXTRACTION
Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care.
DATA SYNTHESIS
From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes.
CONCLUSIONS
Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.
目的
我们系统地回顾了以重症监护病房（ICU）为基础的知识转化研究，以评估知识转化干预对护理过程和结局的影响。
资料来源
我们无语言限制地检索了电子数据库（截至 2010 年 7 月），并手工检索了相关研究和综述的参考文献列表。
研究选择
两名评审员独立识别了比较任何以 ICU 为基础的知识转化干预（例如，方案、指南以及审核和反馈）与无知识转化干预的管理的随机对照试验和观察性研究。我们专注于研究内容大于或等于 5 项研究的临床课题。
资料提取
评审员对临床课题、知识转化干预、护理过程措施和患者结局进行了数据提取。对于研究内容大于或等于 3 项研究涉及的单个或组合知识转化干预，我们使用二项式过程措施的中位数风险比和连续过程措施的标准化均数差来总结每个研究。我们使用随机效应模型。鉴于随机对照试验数量较少，我们的主要荟萃分析包括了随机对照试验和观察性研究。在单独的敏感性分析中，我们排除了随机对照试验，并将方案、指南和捆绑在一起归入一类干预措施。我们对与护理过程改进相关的干预措施的临床结局（ICU 和医院死亡率、呼吸机相关性肺炎、机械通气时间和 ICU 住院时间）进行了荟萃分析。
资料综合
从 11742 篇文献中，我们纳入了 9 个临床课题的 119 项研究（7 项随机对照试验，112 项观察性研究）。包含方案（无论是否有教育）的干预措施可改善连续过程措施（7 项观察性研究和 1 项随机对照试验；标准化均数差[95%CI]：0.26[0.1，0.42]；p=0.001 和 4 项观察性研究和 1 项随机对照试验；0.83[0.37，1.29]；p=0.0004）。各课题内研究间的异质性从低到极高不等。排除随机对照试验并没有改变我们的结果。单干预和低质量研究的标准化均数差高于多干预和高质量研究（p=0.013 和 0.016）。临床结局没有相关改善。
结论
包含方案（无论是否有教育）的 ICU 知识转化干预与重症监护过程的最大改善相关。
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