Intensive Care Med. 2015 Dec;41(12):2149-60. doi: 10.1007/s00134-015-4076-7.
Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs.
Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients' data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score.
ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15-0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904-0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased.
In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.
有关新兴国家重症监护病房（ICU）的组织和护理流程的详细信息很少。在这里，我们调查了组织因素对大量巴西 ICU 患者结局和资源利用的影响。
这是一项对 2013 年期间 78 个 ICU 中 59693 例（内科就诊占 67%）患者进行的回顾性队列研究。我们从 ICU 质量登记处获取了患者数据，并对 ICU 的结构、组织、人员配备模式和护理流程进行了调查。我们使用多水平逻辑回归分析来确定与医院死亡率相关的因素。通过估计调整 SAPS 3 评分后的标准化资源利用和死亡率来评估有效资源利用。
ICU 主要是内科-外科（79%），并位于私立医院（86%）。中位数护士与床位比为 0.20（IQR，0.15-0.28），在 16 个 ICU（21%）中，有 24/7 配备有认证的重症监护医师。67 个 ICU（86%）进行了多学科查房，36 个 ICU（46%）使用了每日检查表。最常见的方案侧重于脓毒症管理和预防医源性感染。医院死亡率为 14.4%。多变量分析显示，方案数量是唯一与死亡率相关的组织特征[比值比=0.944（95%CI 0.904-0.987）]。方案的效果在包括外科和内科患者以及 SAPS 3 三分位数的亚组中是一致的。我们还观察到，随着方案数量的增加，资源利用效率呈显著提高趋势。
在巴西等新兴国家，组织因素，包括实施方案，可能是改善 ICU 患者结局和资源利用的目标。
