因脓毒症住院患者中与使用“不要复苏”医嘱相关的患者及医院层面特征。
Patient and hospital-level characteristics associated with the use of do-not-resuscitate orders in patients hospitalized for sepsis.
作者信息
Chang Dong W, Brass Eric P
机构信息
Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomed Research Institute, Harbor-University of California Los Angeles Medical Center, Torrance, CA, USA,
出版信息
J Gen Intern Med. 2014 Sep;29(9):1256-62. doi: 10.1007/s11606-014-2906-x. Epub 2014 Jun 14.
BACKGROUND
Identifying factors associated with do-not-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed.
METHODS
A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders.
RESULTS
Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order.
CONCLUSION
Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .
背景
识别与“不要复苏”（DNR）医嘱相关的因素是制定改善其使用策略的重要一步。因此，对脓毒症住院早期和晚期使用DNR医嘱的相关因素进行了描述性分析。
方法
利用全州行政数据库确定因脓毒症住院的成年患者回顾性队列。住院24小时内开具的DNR医嘱（早期DNR）和住院24小时后开具的DNR医嘱（晚期DNR）是主要结局变量。采用多变量逻辑回归分析确定与早期和晚期DNR医嘱使用相关的患者、医院及医疗系统相关因素。
结果
在77329例因脓毒症住院的患者中，27.5%在住院期间有DNR医嘱。在有DNR医嘱的病例中，75.5%在住院24小时内开具了该医嘱。医院规模较小且没有教学项目会增加开具早期DNR医嘱的可能性。此外，患者年龄较大、女性、白人种族、更多的内科合并症、医疗保险支付者状态以及从熟练护理机构入院均与开具早期DNR医嘱的可能性显著相关。这些因素与晚期DNR医嘱使用之间的关联强度较弱。相比之下，内科合并症负担越重，患者越有可能接受晚期DNR医嘱。
结论
脓毒症患者使用DNR医嘱与多种患者、医院及医疗系统相关因素有关，其中许多因素似乎与患者的临床状态无关。在住院过程中，内科疾病负担相对于其他变量显示出更强的关联。在改善DNR医嘱使用的策略中需要认识到这些多层次因素的影响。
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