Saft Howard L, Richman Paul S, Berman Andrew R, Mularski Richard A, Kvale Paul A, Ray Daniel E, Selecky Paul, Ford Dee W, Asch Steven M
J Grad Med Educ. 2014 Mar;6(1):44-9. doi: 10.4300/JGME-06-01-38.
Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life.
We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6 months of life for patients with chronic illness.
Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6 months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service.
For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use.
We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.
临终时重症监护病房（ICU）的使用率正在上升。很少有研究关注重症医学专科住院医师培训、机构支持和床边工具与临终时ICU使用之间的关联。
我们评估了医院和重症医学项目干预措施是否与慢性病患者生命最后6个月的ICU使用情况相关。
我们的观察性回顾性研究探讨了重症医学项目主任调查结果与医院层面关于生命最后6个月ICU使用情况的医疗保险数据之间的关联。项目主任评估了其重症医学专科住院医师培训中姑息治疗教育的质量，并报告了床边工具的数量以及是否存在住院姑息治疗咨询服务。
对于分析的89家医院和71个附属培训项目，在ICU使用情况方面，两个解释变量——姑息治疗教育质量和床边工具数量——之间存在统计学上的显著关系。教育质量每提高一个等级（1 - 5李克特量表），ICU使用天数减少0.57天，而每增加一种循证床边工具，ICU使用天数减少0.31天。住院姑息治疗项目的存在并非ICU使用的显著预测因素。
我们发现，重症医学项目中姑息治疗培训的质量和床边工具的使用与临终时ICU使用的减少独立相关。
