Liu Vincent, Herbert David, Foss-Durant Anne, Marelich Gregory P, Patel Anandray, Whippy Alan, Turk Benjamin J, Ragins Arona I, Kipnis Patricia, Escobar Gabriel J
1Division of Research, Kaiser Permanente, Oakland, CA.2The Permanente Medical Group, Kaiser Permanente, Oakland, CA.3Kaiser Foundation Hospitals and Health Plan, Kaiser Permanente, Oakland, CA.4Decision Support, Kaiser Permanente, Oakland, CA.
Crit Care Med. 2016 Mar;44(3):460-7. doi: 10.1097/CCM.0000000000001462.
To evaluate process metrics and outcomes after implementation of the "Rethinking Critical Care" ICU care bundle in a community setting.
Retrospective interrupted time-series analysis.
Three hospitals in the Kaiser Permanente Northern California integrated healthcare delivery system.
ICU patients admitted between January 1, 2009, and August 30, 2013.
Implementation of the Rethinking Critical Care ICU care bundle which is designed to reduce potentially preventable complications by focusing on the management of delirium, sedation, mechanical ventilation, mobility, ambulation, and coordinated care. Rethinking Critical Care implementation occurred in a staggered fashion between October 2011 and November 2012.
We measured implementation metrics based on electronic medical record data and evaluated the impact of implementation on mortality with multivariable regression models for 24,886 first ICU episodes in 19,872 patients. After implementation, some process metrics (e.g., ventilation start and stop times) were achieved at high rates, whereas others (e.g., ambulation distance), available late in the study period, showed steep increases in compliance. Unadjusted mortality decreased from 12.3% to 10.9% (p < 0.01) before and after implementation, respectively. The adjusted odds ratio for hospital mortality after implementation was 0.85 (95% CI, 0.73-0.99) and for 30-day mortality was 0.88 (95% CI, 0.80-0.97) compared with before implementation. However, the mortality rate trends were not significantly different before and after Rethinking Critical Care implementation. The mean duration of mechanical ventilation and hospital stay also did not demonstrate incrementally greater declines after implementation.
Rethinking Critical Care implementation was associated with changes in practice and a 12-15% reduction in the odds of short-term mortality. However, these findings may represent an evaluation of changes in practices and outcomes still in the midimplementation phase and cannot be directly attributed to the elements of bundle implementation.
评估在社区环境中实施“重新思考重症监护”重症监护病房护理套餐后的过程指标和结果。
回顾性中断时间序列分析。
北加利福尼亚凯撒医疗集团综合医疗服务系统中的三家医院。
2009年1月1日至2013年8月30日期间入住重症监护病房的患者。
实施“重新思考重症监护”重症监护病房护理套餐，该套餐旨在通过关注谵妄、镇静、机械通气、活动能力、下床活动及协调护理的管理来减少潜在可预防的并发症。“重新思考重症监护”的实施在2011年10月至2012年11月期间以交错的方式进行。
我们基于电子病历数据测量实施指标，并使用多变量回归模型评估实施对19872例患者中24886次首次重症监护病房发作的死亡率的影响。实施后，一些过程指标（如通气开始和停止时间）的达成率很高，而其他指标（如下床活动距离，在研究后期才有数据）显示依从性急剧增加。实施前后，未调整的死亡率分别从12.3%降至10.9%（p<0.01）。与实施前相比，实施后医院死亡率的调整比值比为0.85（95%CI，0.73-0.99），30天死亡率的调整比值比为0.88（95%CI，0.80-0.97）。然而，“重新思考重症监护”实施前后的死亡率趋势没有显著差异。实施后机械通气的平均持续时间和住院时间也没有显示出更大幅度的下降。
“重新思考重症监护”的实施与实践变化以及短期死亡几率降低12%-15%相关。然而，这些发现可能代表了对仍处于实施中期的实践和结果变化的评估，不能直接归因于护理套餐实施的各个要素。
