基于方案的复苏捆绑治疗方案以改善脓毒性休克患者的结局：密歇根州健康和医院协会基石脓毒症协作的评估。

Protocol-Based Resuscitation Bundle to Improve Outcomes in Septic Shock Patients: Evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative.

机构信息

1Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.2Keystone Center for Patient Safety & Quality, Michigan Health & Hospital Association, Okemos, MI.3Division of Pulmonary, Critical Care, and Sleep Medicine, Henry Ford Health System, Detroit, MI.4St. Joseph Mercy Hospital, Ann Arbor, MI.

出版信息

Crit Care Med. 2016 Dec;44(12):2123-2130. doi: 10.1097/CCM.0000000000001867.

DOI:10.1097/CCM.0000000000001867

PMID:27441897

Abstract

OBJECTIVES

To evaluate the impact of a multi-ICU quality improvement collaborative implementing a protocol-based resuscitation bundle to treat septic shock patients.

DESIGN

A difference-in-differences analysis compared patient outcomes in hospitals participating in the Michigan Health & Hospital Association Keystone Sepsis collaborative (n = 37) with noncollaborative hospitals (n = 50) pre- (2010-2011) and postimplementation (2012-2013). Collaborative hospitals were also stratified as high (n = 19) and low (n = 18) adherence based on their overall bundle adherence.

SETTING

Eighty-seven Michigan hospitals with ICUs.

PATIENTS

We compared 22,319 septic shock patients in collaborative hospitals compared to 26,055 patients in noncollaborative hospitals using the Michigan Inpatient Database.

INTERVENTIONS

Multidisciplinary ICU teams received informational toolkits, standardized screening tools, and continuous quality improvement, aided by cultural improvement.

MEASUREMENTS AND MAIN RESULTS

In-hospital mortality and hospital length of stay significantly improved between pre- and postimplementation periods for both collaborative and noncollaborative hospitals. Comparing collaborative and noncollaborative hospitals, we found no additional reductions in mortality (odds ratio, 0.94; 95% CI, 0.87-1.01; p = 0.106) or length of stay (-0.3 d; 95% CI, -0.7 to 0.1 d; p = 0.174). Compared to noncollaborative hospitals, high adherence hospitals had significant reductions in mortality (odds ratio, 0.84; 95% CI, 0.79-0.93; p < 0.001) and length of stay (-0.7 d; 95% CI, -1.1 to -0.2; p < 0.001), whereas low adherence hospitals did not (odds ratio, 1.07; 95% CI, 0.97-1.19; p = 0.197; 0.2 d; 95% CI, -0.3 to 0.8; p = 0.367).

CONCLUSIONS

Participation in the Keystone Sepsis collaborative was unable to improve patient outcomes beyond concurrent trends. High bundle adherence hospitals had significantly greater improvements in outcomes, but further work is needed to understand these findings.

摘要

目的

评估一个多 ICU 质量改进协作项目实施基于方案的复苏包治疗脓毒症休克患者的效果。

设计

采用差异分析法比较密歇根州卫生与医院协会 Keystone Sepsis 协作组（n=37）和非协作组（n=50）参与医院在实施前（2010-2011 年）和实施后（2012-2013 年）的患者结局。根据整体包管依从性，协作医院还分为高（n=19）和低（n=18）依从性。

地点

密歇根州 87 家设有 ICU 的医院。

患者

我们比较了协作医院的 22319 例脓毒症休克患者和非协作医院的 26055 例患者，使用密歇根州住院患者数据库。

干预

多学科 ICU 团队接受了信息工具包、标准化筛查工具和持续质量改进，并通过文化改进提供帮助。

测量和主要结果

协作和非协作医院在实施前和实施后期间，院内死亡率和住院时间均显著改善。比较协作和非协作医院，我们发现死亡率（比值比，0.94；95%CI，0.87-1.01；p=0.106）或住院时间（-0.3 天；95%CI，-0.7 至 0.1 天；p=0.174）无额外降低。与非协作医院相比，高依从性医院死亡率显著降低（比值比，0.84；95%CI，0.79-0.93；p<0.001）和住院时间（-0.7 天；95%CI，-1.1 至 -0.2；p<0.001），而低依从性医院则没有（比值比，1.07；95%CI，0.97-1.19；p=0.197；0.2 天；95%CI，-0.3 至 0.8；p=0.367）。