Dean Dylan, Martinez Michael S, Newgard Craig D
The Center for Policy and Research in Emergency Medicine, Division of Emergency Medicine, Oregon Health and Science University (OHSU), Portland, OR.
Acad Emerg Med. 2015 Jan;22(1):54-60. doi: 10.1111/acem.12555. Epub 2014 Dec 24.
The objective was describe the use of early do not attempt resuscitation (DNAR) orders in patients with serious traumatic brain injury (TBI) and its association with outcomes.
This was a retrospective cohort study of all serious TBI patients admitted through the emergency department (ED) to acute care hospitals in California between 2002 and 2010 using ED International Classification of Diseases, 9th revision (ICD-9), admitting diagnosis codes specifying intracranial hemorrhage. DNAR placement within 24 hours of admission was the primary variable of interest. Outcomes included neurosurgical procedures and in-hospital mortality. Hospital and patient characteristics were analyzed using descriptive statistics and multivariable generalized estimation equation regression models to account for hospital-level clustering.
Of all 76,962 patients with serious TBI, 71,275 were admitted at 141 hospitals that each cared for at least 10 serious TBI patients annually and formed the primary sample. Early DNAR orders were placed in 7.5% of patients (range = 0 to 36.1% by hospital). Early DNAR use varied by trauma designation: Level I, 4.0% (95% confidence interval [CI] = 3.8% to 4.4%); Level II, 6.7% (95% CI = 6.5% to 7.1%); Level III, 9.7% (95% CI = 8.4% to 11.3%); and nontrauma hospitals, 10.8% (95% CI = 10.6% to 11.3%). Early DNAR was also less likely in teaching hospitals (9.3% vs. 4.3%). These results persisted after accounting for age, year, and hospital-level clustering. In-hospital mortality (39.4% vs. 8.7%) and neurosurgical interventions (14.5% vs. 19.7%) also differed for patients with versus without early DNAR orders. Patients 65 years of age and older constituted 87.7% of those with early DNAR orders; our findings remained qualitatively unchanged when restricted to older adults.
Use of early DNAR orders among patients with serious TBI is highly variable by individual hospital and hospital type, suggesting substantial practice variation. Associations with fewer surgical intervention and higher mortality suggest that such practice variation may be contributing to differences in TBI outcomes, particularly among older adults.
本研究旨在描述严重创伤性脑损伤（TBI）患者早期不进行心肺复苏（DNAR）医嘱的使用情况及其与预后的关系。
这是一项回顾性队列研究，研究对象为2002年至2010年间通过急诊科（ED）收治于加利福尼亚州急性护理医院的所有严重TBI患者，使用ED国际疾病分类第九版（ICD-9），入院诊断代码明确为颅内出血。入院24小时内下达DNAR医嘱是主要研究变量。预后指标包括神经外科手术和院内死亡率。使用描述性统计分析医院和患者特征，并使用多变量广义估计方程回归模型来考虑医院层面的聚类情况。
在所有76,962例严重TBI患者中，71,275例在141家医院入院，每家医院每年至少收治10例严重TBI患者，这些患者构成了主要样本。7.5%的患者下达了早期DNAR医嘱（各医院范围为0至36.1%）。早期DNAR的使用因创伤指定级别而异：一级创伤中心为4.0%（95%置信区间[CI]=3.8%至4.4%）；二级创伤中心为6.7%（95%CI=6.5%至7.1%）；三级创伤中心为9.7%（95%CI=8.4%至11.3%）；非创伤医院为10.8%（95%CI=10.6%至11.3%）。教学医院早期下达DNAR医嘱的可能性也较低（9.3%对4.3%）。在考虑年龄、年份和医院层面的聚类情况后，这些结果仍然存在。有早期DNAR医嘱和无早期DNAR医嘱的患者在院内死亡率（39.4%对8.7%）和神经外科干预（14.5%对19.7%）方面也存在差异。65岁及以上的患者占下达早期DNAR医嘱患者的87.7%；当仅纳入老年人时，我们的研究结果在定性上没有变化。
严重TBI患者早期DNAR医嘱的使用在不同医院和医院类型之间差异很大，表明实践存在很大差异。与较少的手术干预和较高的死亡率相关，表明这种实践差异可能导致TBI预后的差异，特别是在老年人中。
