1Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA. 2Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. 3University of Pittsburgh Medical Center, Pittsburgh, PA. 4Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA.
Crit Care Med. 2014 Apr;42(4):896-904. doi: 10.1097/CCM.0000000000000052.
Evidence-based practices are not consistently applied in the ICU. We sought to determine if nurse-led remote screening and prompting for evidence-based practices using an electronic health record could impact ICU care delivery and outcomes in an academic medical center.
Single-center, before-after evaluation of a quality improvement project.
Urban, academic medical center in the mid-Atlantic United States with eight subspecialty ICUs and 156 ICU beds.
Adult patients admitted to the ICU between January 1, 2011, and August 31, 2012.
Beginning on July 25, 2011, trained ICU nurses screened all ICU patients for selected evidence-based practices on a daily basis. The screening was conducted from a remote office, facilitated by the electronic health record. Selected practices included compliance with a ventilator care bundle, assessment of appropriateness of indwelling venous and urinary catheters, and concordance between sedation orders and documented level of sedation. When gaps were observed, they were communicated to the point-of-care bedside nurse via telephone, page, or facsimile.
Fourteen thousand eight hundred twenty-three unique patients were admitted during the study period. We excluded 1,546 patients during a 2-month run-in period from July 1, 2011, to August 31, 2011, resulting in 4,339 patients in the 6-month preintervention period and 8,938 patients in the 12-month postintervention period. Compared with patients admitted in the preintervention period, patients admitted in the postintervention period were more likely to receive sedation interruption (incidence rate ratio, 1.57; 95% CI, 1.45-1.71) and a spontaneous breathing trial (incidence rate ratio, 1.24; 95% CI, 1.20-1.29). Hospital-acquired infection rates were not different between the two periods. Adjusting for patient characteristics and illness severity, patients in the postintervention period experienced shorter duration of mechanical ventilation (adjusted reduction, 0.61 d; 95% CI, 0.27-0.96; p < 0.001), shorter ICU length of stay (adjusted reduction, 0.22 d; 95% CI, 0.04-0.41; p = 0.02), and shorter hospital length of stay (adjusted reduction, 0.55 d; 95% CI, 0.15-0.93; p = 0.006). In-hospital mortality was unchanged (adjusted odds ratio, 0.96; 95% CI, 0.84-1.09; p = 0.54). The results were robust to tests for concurrent temporal trends and coincident interventions.
A program by which nurses screened ICU patients for best practices from a remote location was associated with improvements in the quality of care and reductions in duration of mechanical ventilation and length of stay, but had no impact on mortality.
循证实践在 ICU 中并未得到一致应用。我们旨在确定使用电子病历由护士主导的远程筛查和提示是否能影响学术医疗中心的 ICU 护理提供和结果。
在一个质量改进项目中进行的单中心前后评估。
位于美国中大西洋地区的城市学术医疗中心，设有 8 个专科 ICU 和 156 张 ICU 病床。
2011 年 1 月 1 日至 2012 年 8 月 31 日期间入住 ICU 的成年患者。
自 2011 年 7 月 25 日起，受过培训的 ICU 护士每天对所有 ICU 患者进行选定的循证实践筛查。筛查在远程办公室中通过电子病历进行。选定的实践包括遵循呼吸机护理包、评估留置静脉和导尿管的适宜性，以及镇静医嘱与记录的镇静水平之间的一致性。当发现差距时，通过电话、传呼或传真将其传达给床边护理护士。
在研究期间，共有 14823 名独特患者入院。我们在 2011 年 7 月 1 日至 2011 年 8 月 31 日的 2 个月运行期内排除了 1546 名患者，因此在 6 个月的干预前期间有 4339 名患者，在 12 个月的干预后期间有 8938 名患者。与干预前期间入院的患者相比，干预后期间入院的患者更有可能接受镇静中断（发生率比，1.57；95%置信区间，1.45-1.71）和自主呼吸试验（发生率比，1.24；95%置信区间，1.20-1.29）。两个时期的医院获得性感染率没有差异。调整患者特征和疾病严重程度后，干预后期间的患者机械通气时间更短（调整减少，0.61d；95%置信区间，0.27-0.96；p<0.001），ICU 住院时间更短（调整减少，0.22d；95%置信区间，0.04-0.41；p=0.02），住院时间更短（调整减少，0.55d；95%置信区间，0.15-0.93；p=0.006）。住院死亡率没有变化（调整比值比，0.96；95%置信区间，0.84-1.09；p=0.54）。这些结果对同时进行的时间趋势和并发干预的测试具有稳健性。
由护士从远程位置对 ICU 患者进行最佳实践筛查的计划与护理质量的改善以及机械通气时间和住院时间的缩短有关，但对死亡率没有影响。
