重症监护病房护理水平与质量的关联
The Association of Level of Care With NICU Quality.
作者信息
Profit Jochen, Gould Jeffrey B, Bennett Mihoko, Goldstein Benjamin A, Draper David, Phibbs Ciaran S, Lee Henry C
机构信息
Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California;
Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina;
出版信息
Pediatrics. 2016 Mar;137(3):e20144210. doi: 10.1542/peds.2014-4210. Epub 2016 Feb 9.
BACKGROUND
Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.
METHODS
We conducted a cross-sectional analysis of 21,051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.
RESULTS
Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.
CONCLUSIONS
The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.
背景
区域化医疗服务据称能优化对极早产儿（出生体重极低；<1500克）的护理。然而，尚未对不同级别新生儿重症监护病房（NICU）的护理质量进行全面评估。
方法
我们对加利福尼亚州134家新生儿重症监护病房的21,051名极低出生体重婴儿进行了横断面分析。各新生儿重症监护病房根据2012年美国儿科学会指南指定其护理级别。我们通过“婴儿监测指标（Baby-MONITOR）”评估护理质量，这是一个综合指标，结合了9项经风险调整的质量指标。婴儿监测指标得分以观察到的表现减去预期表现来衡量，以标准单位表示，均值为0，标准差为1。
结果
加利福尼亚州各医院的婴儿监测指标得分差异很大（均值[标准差]0.18（1.14），范围为-2.26至3.39）。然而，护理级别与总体质量得分无关。子成分分析显示，四级新生儿重症监护病房在多项过程指标上表现出更高水平的趋势，包括产前使用类固醇和出院时任何母乳喂养，但在包括任何与医疗保健相关的感染、气胸和生长速度等多项结果指标上得分较低。没有其他卫生系统或组织因素，包括医院所有权、新生儿科医生覆盖率、城市或农村位置以及医院教学状况，与婴儿监测指标得分有显著关联。
结论
对护理级别对质量的影响进行全面评估，揭示了不同的改进机会，并有助于监测确保脆弱的极低出生体重婴儿在适当设施中接受护理的工作。
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