Haddad Samir H, Gonzales Catherine B, Deeb Ahmad M, Tamim Hani M, AlDawood Abdulaziz S, Al Babtain Ibrahim, Naidu Brintha S, Arabi Yaseen M
King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.
The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
BMC Anesthesiol. 2015 Dec 7;15:177. doi: 10.1186/s12871-015-0161-2.
Computerized Physician Order Entry (CPOE) analgesia-sedation protocols may improve sedation practice and patients' outcomes. We aimed to evaluate the impact of the introduction of CPOE protocol.
This was a prospective, observational cohort study of adult patients receiving mechanical ventilation, requiring intravenous infusion of analgesics and/or sedatives, and expected to stay in the intensive care unit (ICU) ≥24 h. As a quality improvement project, the study had three phases: phase 1, no protocol, July 1st to September 30th, 2010; phase 2, post implementation of CPOE protocol, October 1st to December 31st, 2010; and phase 3, revised (age, kidney and liver function adjusted) CPOE protocol, August 1st to October 31st, 2011. Multivariate analyses were performed to determine the independent predictors of mortality.
Two hundred seventy nine patients were included (no protocol = 91, CPOE protocol = 97, revised CPOE protocol = 91). Implementation of CPOE protocol was associated with increase of the average daily dose of fentanyl (3720 ± 3286 vs. 2647 ± 2212 mcg/day; p = 0.009) and decrease of hospital length of stay (40 ± 37 vs. 63 ± 85 days, p = 0.02). The revised CPOE protocol was associated with, compared to the CPOE protocol, a decrease of the average daily dose of fentanyl (2208 ± 2115 vs. 3720 ± 3286 mcg/day, p = 0.0002) and lorazepam (0 ± 0 vs. 0.06 ± 0.26 mg/day, p = 0.04), sedation-related complications during ICU stay (3.3 % vs. 29.9 %, p <0.0001), and ICU mortality (18 % vs. 39 %, p = 0.001). The impact of the revised CPOE protocol was more evident on patients aged >70 years or with severe kidney or liver impairment. Both the original CPOE protocol and the revised CPOE protocol were not independent predictors of ICU (adjusted odds ratio [aOR] = 1.85, confidence interval [CI] = 0.90-3.78; p = 0.09; aOR = 0.70, CI = 0.32-1.53, p = 0.37; respectively) or hospital mortality (aOR = 1.12, CI = 0.57-2.21, p = 0.74; aOR = 0.80, CI = 0.40-1.59, p = 0.52; respectively).
The implementation of a CPOE analgesia-sedation protocol was not associated with improved sedation practices or patients' outcome but with unpredicted increases of an analgesic dose. However, the revised CPOE protocol (age, kidney and liver function adjusted) was associated with improved sedation practices. This study highlights the importance of carefully evaluating the impact of changes in practice to detect unanticipated outcomes.
计算机化医师医嘱录入(CPOE)镇痛镇静方案可能会改善镇静实践及患者预后。我们旨在评估引入CPOE方案的影响。
这是一项针对接受机械通气、需要静脉输注镇痛药和/或镇静剂且预计在重症监护病房(ICU)住院≥24小时的成年患者的前瞻性观察队列研究。作为一项质量改进项目,该研究分为三个阶段:第1阶段,无方案阶段,2010年7月1日至9月30日;第2阶段,CPOE方案实施后阶段,2010年10月1日至12月31日;第3阶段,修订(根据年龄、肾功能和肝功能调整)CPOE方案阶段,2011年8月1日至10月31日。进行多变量分析以确定死亡率的独立预测因素。
共纳入279例患者(无方案组=91例,CPOE方案组=97例,修订CPOE方案组=91例)。CPOE方案的实施与芬太尼平均日剂量增加(3720±3286 vs. 2647±2212微克/天;p=0.009)及住院时间缩短(40±37 vs. 63±85天,p=0.02)相关。与CPOE方案相比,修订后的CPOE方案与芬太尼平均日剂量降低(2208±2115 vs. 3720±3286微克/天,p=0.0002)、劳拉西泮平均日剂量降低(0±0 vs. 0.06±0.26毫克/天,p=0.04)、ICU住院期间镇静相关并发症减少(3.3% vs. 29.9%,p<0.0001)及ICU死亡率降低(18% vs. 39%,p=0.001)相关。修订后的CPOE方案对年龄>70岁或有严重肝肾功能损害的患者影响更明显。原始CPOE方案和修订后的CPOE方案均不是ICU(校正比值比[aOR]=1.85,置信区间[CI]=0.90 - 3.78;p=0.09;aOR=0.70,CI=0.32 - 1.53,p=0.37)或医院死亡率(aOR=1.12,CI=0.57 - 2.21,p=0.74;aOR=0.8着,CI=0.40 - 1.59,p=0.52)的独立预测因素。
CPOE镇痛镇静方案的实施与改善镇静实践或患者预后无关,但与镇痛药剂量意外增加有关。然而,修订后的CPOE方案(根据年龄、肾功能和肝功能调整)与改善镇静实践相关。本研究强调了仔细评估实践变化的影响以发现意外结果的重要性。