Benoit Marc A, Bagshaw Sean M, Norris Colleen M, Zibdawi Mohamad, Chin Wu Dat, Ross David B, van Diepen Sean
1Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. 2Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. 3Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. 4Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
Crit Care Med. 2017 Jun;45(6):993-1000. doi: 10.1097/CCM.0000000000002434.
Nighttime intensivist staffing does not improve patient outcomes in general ICUs. Few studies have examined the association between dedicated in-house 24/7 intensivist coverage on outcomes in specialized cardiac surgical ICUs. We sought to evaluate the association between 24/7 in-house intensivist-only management of cardiac surgical patients on postoperative complications and health resource utilization.
Before-and-after propensity matched cohort study.
Tertiary care cardiac surgical ICU.
Patients greater than 18 years old who underwent cardiac surgery between January 1, 2006, and April 30, 2013 (nighttime resident model), were propensity-matched (1:1) to patients from August 1, 2013, to December 31, 2014 (24/7 in-house intensivist model).
Cardiac surgical ICU coverage change from a nighttime resident physician coverage model to a 24/7 in-house intensivist staffing model.
The primary outcome of interest was a composite of postoperative major complications. Secondary outcomes included duration of mechanical ventilation, all-cause cardiac surgical ICU readmissions, and surgical postponements attributed to lack of cardiac surgical ICU bed availability. A total of 1,509 patients during the nighttime resident model were matched to 1,509 patients during the intensivist model. The adjusted risk of major complications (26.3% vs 19.3%; odds ratio, 0.73; 95% CI, 0.36-0.85; p < 0.01), mean mechanical ventilation time (25.2 vs 19.4 hr; p < 0.01), cardiac surgical ICU readmissions (5.3% vs 1.6%; odds ratio, 0.31; 95% CI, 0.19-0.48; p < 0.01), and surgical postponements (3.4 vs 0.3 per mo; p < 0.01) were lower with the intensivist model.
A transition to a 24/7 in-house intensivist care model was associated with a reduction in postoperative major complications, duration of mechanical ventilation, cardiac surgical ICU readmissions, and surgical postponements. These findings suggest that 24/7 intensivist physician care models may improve patient outcomes and health resource utilization in specialized cardiac surgical ICUs.
在普通重症监护病房（ICU）中，夜间安排重症监护医生并不能改善患者预后。很少有研究探讨在专门的心脏外科ICU中，全天候由专职重症监护医生负责对患者预后的影响。我们试图评估在心脏外科患者中，由重症监护医生全天候专职管理与术后并发症及医疗资源利用之间的关系。
前后倾向匹配队列研究。
三级医疗心脏外科ICU。
2006年1月1日至2013年4月30日期间接受心脏手术的18岁以上患者（夜间住院医师模式），与2013年8月1日至2014年12月31日期间的患者（全天候专职重症监护医生模式）进行倾向匹配（1:1）。
心脏外科ICU的覆盖模式从夜间住院医师覆盖模式转变为全天候专职重症监护医生配备模式。
主要关注的结局是术后严重并发症的综合情况。次要结局包括机械通气时间、心脏外科ICU因各种原因的再入院率，以及因心脏外科ICU床位不足导致的手术延期情况。夜间住院医师模式下共有1509例患者与专职重症监护医生模式下的1509例患者相匹配。专职重症监护医生模式下，调整后的严重并发症风险（26.3%对19.3%；比值比，0.73；95%可信区间，0.36 - 0.85；p < 0.01）、平均机械通气时间（25.2对19.4小时；p < 0.01）、心脏外科ICU再入院率（5.3%对1.6%；比值比，0.31；95%可信区间，0.19 - 0.48；p < 0.01）以及手术延期情况（每月3.4次对0.3次；p < 0.01）均较低。
向全天候专职重症监护医生护理模式的转变与术后严重并发症、机械通气时间、心脏外科ICU再入院率及手术延期情况的减少相关。这些发现表明，全天候重症监护医生护理模式可能改善专门心脏外科ICU中的患者预后及医疗资源利用情况。
