重症患者的诊疗方案与医院死亡率：美国重症疾病与损伤试验组重症疾病结局研究
Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study.
作者信息
Sevransky Jonathan E, Checkley William, Herrera Phabiola, Pickering Brian W, Barr Juliana, Brown Samuel M, Chang Steven Y, Chong David, Kaufman David, Fremont Richard D, Girard Timothy D, Hoag Jeffrey, Johnson Steven B, Kerlin Mehta P, Liebler Janice, O'Brien James, O'Keefe Terence, Park Pauline K, Pastores Stephen M, Patil Namrata, Pietropaoli Anthony P, Putman Maryann, Rice Todd W, Rotello Leo, Siner Jonathan, Sajid Sahul, Murphy David J, Martin Greg S
机构信息
1Division of Pulmonary, Allergy and Critical Care, Emory University, Atlanta, GA. 2Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD. 3Department of Anesthesia, Mayo Clinic, Rochester, MN. 4Department of Anesthesiology, Stanford University, Palo Alto, CA. 5Division of Pulmonary and Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City, UT. 6Division of Pulmonary and Critical Care, UCLA, Los Angeles, CA. 7Division of Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, NY. 8Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, CT. 9Division of Pulmonary and Critical Care, Meharry Medical College, Nashville, TN. 10Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research at the, Vanderbilt University School of Medicine, Nashville, TN. 11Division of Pulmonary and Critical Care, Drexel University, Philadelphia, PA. 12Department of Surgical Critical Care, University of Maryland, Baltimore, MD. 13Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA. 14Division of Pulmonary Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA. 15Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Ohio State University, Columbus, OH. 16Department of Surgery, University of Arizona, Tucson, AZ. 17Division of Acute Care Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI. 18Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY. 19Department of Surgery, Division of Thoracic Surgery, Division of Trauma, Burn & Critical Care, Brigham and Women's Hospital, Boston, MA. 20Division of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, NY. 21INOVA Fairfax Hospital, Falls Church, VA. 22Suburban Hospital, Bethesda, MD. 23Department of A
出版信息
Crit Care Med. 2015 Oct;43(10):2076-84. doi: 10.1097/CCM.0000000000001157.
OBJECTIVE
Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized ICUs have superior patient outcomes compared with less highly protocolized ICUs.
DESIGN
Observational study in which participating ICUs completed a general assessment and enrolled new patients 1 day each week.
PATIENTS
A total of 6,179 critically ill patients.
SETTING
Fifty-nine ICUs in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
The primary exposure was the number of ICU protocols; the primary outcome was hospital mortality. A total of 5,809 participants were followed prospectively, and 5,454 patients in 57 ICUs had complete outcome data. The median number of protocols per ICU was 19 (interquartile range, 15-21.5). In single-variable analyses, there were no differences in ICU and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in ICUs with a high versus low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p = 0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between ICUs with high versus low numbers of protocols for lung protective ventilation in acute respiratory distress syndrome (47% vs 52%; p = 0.28) and for spontaneous breathing trials (55% vs 51%; p = 0.27).
CONCLUSIONS
Clinical protocols are highly prevalent in U.S. ICUs. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality.
目的
临床方案可减少护理中不必要的差异，并提高对理想治疗方法的依从性。我们评估了高度规范化的重症监护病房（ICU）与规范化程度较低的ICU相比，患者结局是否更优。
设计
一项观察性研究，参与研究的ICU完成一次综合评估，并每周有一天纳入新患者。
患者
共有6179例危重症患者。
地点
美国危重症与损伤试验组危重症结局研究中的59个ICU。
干预措施
无。
测量指标及主要结果
主要暴露因素是ICU方案的数量；主要结局是医院死亡率。共有5809名参与者被前瞻性随访，57个ICU中的5454例患者有完整的结局数据。每个ICU方案的中位数为19个（四分位间距为15 - 21.5）。在单变量分析中，方案数量多与少的ICU患者在ICU死亡率、医院死亡率、住院时间、机械通气使用、血管升压药使用或持续镇静使用方面均无差异。在调整后的多变量分析中证实了这种缺乏关联的情况（p = 0.70）。对于两项呼吸机管理方案的方案依从性为中等，在急性呼吸窘迫综合征中，肺保护性通气的方案数量多与少的ICU之间（47%对52%；p = 0.28）以及自主呼吸试验方面（55%对51%；p = 0.27）并无差异。
结论
临床方案在美国ICU中非常普遍。方案数量较多与方案依从性或患者死亡率无关。
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