“单行道”式优化流程对危重症创伤患者的收治可缩短急诊科停留时间。

"One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay.

机构信息

Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.

Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.

出版信息

Intern Emerg Med. 2017 Oct;12(7):1019-1024. doi: 10.1007/s11739-016-1511-x. Epub 2016 Jul 29.

DOI:10.1007/s11739-016-1511-x

PMID:27473424

Abstract

Emergency department (ED) overcrowding remains a significant problem in many hospitals, and results in multiple negative effects on patient care outcomes and operational metrics. We sought to test whether implementing a quality improvement project could decrease ED LOS for trauma patients requiring an ICU admission from the ED, specifically by directly admitting critically ill trauma patients from the ED CT scanner to an ICU bed. This was a retrospective study comparing patients during the intervention period (2013-2014) to historical controls (2011-2013). Critically ill trauma patients requiring a CT scan, but not the operating room (OR) or Interventional Radiology (IR), were directly admitted from the CT scanner to the ICU, termed the "One-way street (OWS)". Controls from the 2011-2013 Trauma Registry were matched 1:1 based on the following criteria: Injury Severity Score; mechanism of injury; and age. Only patients who required emergent trauma consult were included. Our primary outcome was ED LOS, defined in minutes. Our secondary outcomes were ICU LOS, hospital LOS and mortality. Paired t test or Wilcoxon signed rank test were used for continuous univariate analysis and Chi square for categorical variables. Logistic regression and linear regressions were used for categorical and continuous multivariable analysis, respectively. 110 patients were enrolled in this study, with 55 in the OWS group and 55 matched controls. Matched controls had lower APACHE II score (12 vs. 15, p = 0.03) and a higher GCS (14 vs. 6, p = 0.04). ED LOS was 229 min shorter in the OWS group (82 vs. 311 min, p < 0.0001). The time between CT performed and ICU disposition decreased by 230 min in the OWS arm (30 vs. 300 min, p < 0.001). There was no difference in ED arrival to CT time between groups. Following multivariable analysis, mortality was primarily predicted by the APACHE II score (OR 1.29, p < 0.001), and not ISS, mechanism of injury, or age. After controlling for APACHE II score, there was no difference in mortality between the two cohorts (OR = 0.49, p = 0.28). Expedited admission of critically ill trauma patients immediately following CT imaging significantly reduced ED LOS by 3.82 h (229 min), without a change in ICU LOS, hospital LOS, or mortality. Further studies are needed to assess the impact of expedited admission on morbidity and mortality.

摘要

急诊科（ED）拥挤仍然是许多医院的一个重大问题，这对患者护理结果和运营指标产生了多个负面影响。我们试图测试实施质量改进项目是否可以减少需要从 ED 转入 ICU 的创伤患者的 ED LOS，具体方法是将从 ED CT 扫描仪直接送入 ICU 病床的重症创伤患者直接送入 ICU。这是一项回顾性研究，比较了干预期间（2013-2014 年）和历史对照（2011-2013 年）的患者。需要进行 CT 扫描但不需要手术室（OR）或介入放射科（IR）的重症创伤患者直接从 CT 扫描仪转入 ICU，称为“单行道（OWS）”。根据损伤严重程度评分、损伤机制和年龄，将 2011-2013 年创伤登记册中的对照患者 1:1 匹配。仅包括需要紧急创伤咨询的患者。我们的主要结果是 ED LOS，以分钟为单位表示。我们的次要结果是 ICU LOS、医院 LOS 和死亡率。连续单变量分析采用配对 t 检验或 Wilcoxon 符号秩检验，分类变量采用卡方检验。逻辑回归和线性回归分别用于分类和连续多变量分析。这项研究共纳入 110 例患者，OWS 组 55 例，匹配对照组 55 例。匹配对照组的 APACHE II 评分较低（12 对 15，p=0.03），GCS 较高（14 对 6，p=0.04）。OWS 组的 ED LOS 缩短了 229 分钟（82 对 311 分钟，p<0.0001）。OWS 臂中 CT 与 ICU 处置之间的时间减少了 230 分钟（30 对 300 分钟，p<0.001）。两组之间的 ED 到达 CT 时间无差异。多变量分析后，死亡率主要由 APACHE II 评分预测（OR 1.29，p<0.001），而不是 ISS、损伤机制或年龄。在控制 APACHE II 评分后，两组之间的死亡率无差异（OR=0.49，p=0.28）。立即在 CT 成像后对重症创伤患者进行紧急入院可显著减少 ED LOS 3.82 小时（229 分钟），而 ICU LOS、医院 LOS 或死亡率无变化。需要进一步研究来评估紧急入院对发病率和死亡率的影响。