Whitehouse Tony, Hodson James, Pemberton Philip, Veenith Tonny, Snelson Catherine, Bion Julian, Rubenfeld Gordon D
1Department of Critical Care and Anaesthesia, University Hospital Birmingham, Edgbaston, Birmingham, United Kingdom. 2University Department of Anaesthesia & Critical Care, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom. 3Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, ON, Canada.
Crit Care Med. 2017 Jun;45(6):949-955. doi: 10.1097/CCM.0000000000002373.
We hypothesized that intensivists unfamiliar with an ICU team and the context of that ICU would affect patient outcomes. We examined differences in mortality when ICU patients were admitted under intensivists routinely working in that ICU and compared with those admitted by intensivists familiar with an ICU elsewhere in the same hospital.
DESIGN, SETTINGS, AND PATIENTS: A 5-year natural experimental crossover study involving patients admitted to four ICUs in a large U.K. teaching hospital.
During a period of service reconfiguration, intensivists routinely rostered to work in one ICU worked in another of the hospital's four ICUs. "Home" intensivists were those who continued to work in their usual ICU; "visitor" intensivists were those who delivered care in an unfamiliar ICU. Patient data were obtained from electronic patient records to provide analysis on sex, age, admission Sequential Organ Failure Assessment score, date and time of admission, and admission type (elective, transfer, or unplanned).
We analyzed 9,981 admissions to four separate ICUs over a 5-year period. In total, 34.5% of patients were admitted by intensivists working in nonfamiliar surroundings. Visitor intensivists admitted patients with similar age and gender distributions but with greater physiologic derangement (mean Sequential Organ Failure Assessment score, 4.1 ± 2.8 vs 3.9 ± 2.8; p < 0.001) than home intensivists. Overall ICU mortality rates were higher in visitor intensivists, albeit not significantly so (11.5% vs 10.2%; p = 0.052). However, when the ICUs were analyzed separately, visitor mortality rates were found to be significantly higher than for home intensivists in two of the four ICUs (p = 0.017, 0.006). A multivariable analysis adjusting for confounding factors and the clustering of consultants revealed that the overall mortality rate was significantly higher for visitors (odds ratio, 1.18; 95% CI, 1.02-1.37; p = 0.024). A significant interaction between the ICU and visitor status was also detected (p = 0.046), with the visitor effect remaining significant in the two ICUs identified previously (both p = 0.009).
Visitor intensivists in some ICUs were associated with higher mortality. The reasons are unknown but could relate to intensivists' practices, unfamiliarity with the patients, or the interaction with the interprofessional team.
我们推测，不熟悉重症监护病房（ICU）团队及该ICU环境的重症医学专家会影响患者的治疗结果。我们研究了在常规工作于该ICU的重症医学专家管理下收治的ICU患者与由同一医院其他地方ICU的熟悉专家收治的患者之间的死亡率差异。
设计、地点和患者：一项为期5年的自然实验交叉研究，涉及一家大型英国教学医院4个ICU收治的患者。
在服务重新配置期间，常规安排在一个ICU工作的重症医学专家在该医院的另外4个ICU之一工作。“常驻”重症医学专家是指继续在其常规ICU工作的人员；“客座”重症医学专家是指在不熟悉的ICU提供治疗的人员。从电子病历中获取患者数据，以分析性别、年龄、入院时序贯器官衰竭评估（SOFA）评分、入院日期和时间以及入院类型（择期、转院或非计划）。
我们分析了5年期间4个不同ICU的9981例入院病例。总体而言，34.5%的患者由在不熟悉环境中工作的重症医学专家收治。客座重症医学专家收治的患者年龄和性别分布相似，但生理紊乱程度比常驻重症医学专家更高（平均SOFA评分：4.1±2.8对3.9±2.8；p<0.001）。客座重症医学专家管理的患者总体ICU死亡率更高，尽管差异不显著（11.5%对10.2%；p = 0.052）。然而，当分别分析各个ICU时，发现在4个ICU中的2个，客座重症医学专家管理的患者死亡率显著高于常驻重症医学专家管理的患者（p = 0.017，0.006）。对混杂因素和顾问聚类进行调整的多变量分析显示，客座重症医学专家管理的患者总体死亡率显著更高（比值比，1.18；95%置信区间，1.02 - 1.37；p = 0.024）。还检测到ICU和客座状态之间存在显著交互作用（p = 0.046），在之前确定的2个ICU中，客座效应仍然显著（均为p = 0.009）。
在某些ICU中，客座重症医学专家与更高的死亡率相关。原因尚不清楚，但可能与重症医学专家的治疗方式、对患者不熟悉或与跨专业团队的互动有关。
