1 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
Am J Respir Crit Care Med. 2014 Jun 1;189(11):1395-401. doi: 10.1164/rccm.201312-2181OC.
Cross-coverage is associated with medical errors caused by miscommunication during handoffs. However, no direct evidence links handoffs to outcomes, or explains the mechanisms leading to outcomes. Furthermore, the previous literature may overestimate the impact of handoffs because of hindsight bias.
To explore the effects of nighttime cross-coverage on mortality and decision making in critically ill patients.
Observational cohort of 629 consecutive critically ill admissions, admitted for at least 48 hours, and critical care fellows in an academic hospital.
Intensive care unit (ICU) mortality and nighttime decisions. Our exposure variable was cross-covering status of fellows. We observed a decrease in ICU mortality (odds ratio, 0.77 per 1 d; 0.60-0.99; P = 0.04), a higher number of nighttime decisions (19.3 vs. 10.4%; odds ratio, 2.02; 95% confidence interval [CI], 1.03-3.95; P = 0.04), an increase in fentanyl equivalents administered to patients at night (difference, +10.2 μg/h; 95% CI, +1.4 to +19.0; P = 0.02), and an increase in transfusions at night (difference, +465 ml; 95% CI, +98 to +832; P = 0.01) when fellows were cross-covering.
In this single-center study exposure to cross-covering fellows was associated with a decrease in ICU mortality and with more nighttime decisions. Our findings contradict the dominant hypothesis that cross-coverage is associated with worse outcomes, and suggest that a "second look" by cross-covering fellows may mitigate cognitive errors. Future interventions to improve patient safety in ICUs should focus both on the quality of handoffs and on strategies to decrease cognitive errors.
交接班时的沟通失误会导致交叉覆盖相关的医疗差错。然而，目前还没有直接证据将交接班与结果联系起来，也无法解释导致结果的机制。此外，由于后见之明偏差，之前的文献可能高估了交接班的影响。
探讨夜间交叉覆盖对危重病患者死亡率和决策的影响。
这是一项观察性队列研究，纳入了 629 例连续入住的危重病患者，入住时间至少 48 小时，以及一家学术医院的重症监护医师。
重症监护病房（ICU）死亡率和夜间决策。我们的暴露变量是医师的交叉覆盖状态。我们观察到 ICU 死亡率降低（比值比，每增加 1 天 0.77；0.60-0.99；P = 0.04），夜间决策增加（19.3%比 10.4%；比值比，2.02；95%置信区间[CI]，1.03-3.95；P = 0.04），夜间给予患者的芬太尼等效物增加（差值，+10.2 μg/h；95%CI，+1.4 至+19.0；P = 0.02），夜间输血增加（差值，+465 ml；95%CI，+98 至+832；P = 0.01）。
在这项单中心研究中，接触交叉覆盖的医师与 ICU 死亡率降低和更多夜间决策相关。我们的发现与交叉覆盖与较差结果相关的主流假设相矛盾，表明交叉覆盖医师的“二次检查”可能减轻认知错误。未来旨在改善 ICU 患者安全性的干预措施应同时关注交接班的质量和减少认知错误的策略。
