入住重症监护病房的无家可归患者与非无家可归患者的特征、临床病程及结局：一项回顾性队列研究。
Characteristics, clinical course, and outcomes of homeless and non-homeless patients admitted to ICU: A retrospective cohort study.
作者信息
Smith Orla M, Chant Clarence, Burns Karen E A, Kaur Maninder, Ashraf Said, DosSantos Claudia C, Hwang Stephen W, Friedrich Jan O
机构信息
Critical Care Department, St. Michael's Hospital, Toronto, Canada.
Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.
出版信息
PLoS One. 2017 Jun 12;12(6):e0179207. doi: 10.1371/journal.pone.0179207. eCollection 2017.
BACKGROUND
Little is known about homeless patients in intensive care units (ICUs).
OBJECTIVES
To compare clinical characteristics, treatments, and outcomes of homeless to non-homeless patients admitted to four ICUs in a large inner-city academic hospital.
METHODS
63 randomly-selected homeless compared to 63 age-, sex-, and admitting-ICU-matched non-homeless patients.
RESULTS
Compared to matched non-homeless, homeless patients (average age 48±12 years, 90% male, 87% admitted by ambulance, 56% mechanically ventilated, average APACHE II 17) had similar comorbidities and illness severity except for increased alcohol (70% vs 17%,p<0.001) and illicit drug(46% vs 8%,p<0.001) use and less documented hypertension (16% vs 40%,p = 0.005) or prescription medications (48% vs 67%,p<0.05). Intensity of ICU interventions was similar except for higher thiamine (71% vs 21%,p<0.0001) and nicotine (38% vs 14%,p = 0.004) prescriptions. Homeless patients exhibited significantly lower Glasgow Coma Scores and significantly more bacterial respiratory cultures. Longer durations of antibiotics, vasopressors/inotropes, ventilation, ICU and hospital lengths of stay were not statistically different, but homeless patients had higher hospital mortality (29% vs 8%,p = 0.005). Review of all deaths disclosed that withdrawal of life-sustaining therapy occurred in similar clinical circumstances and proportions in both groups, regardless of family involvement. Using multivariable logistic regression, homelessness did not appear to be an independent predictor of hospital mortality.
CONCLUSIONS
Homeless patients, admitted to ICU matched to non-homeless patients by age and sex (characteristics most commonly used by clinicians), have higher hospital mortality despite similar comorbidities and illness severity. Trends to longer durations of life supports may have contributed to the higher mortality. Additional research is required to validate this higher mortality and develop strategies to improve outcomes in this vulnerable population.
背景
对于重症监护病房（ICU）中的无家可归患者了解甚少。
目的
比较一家大型市中心学术医院四个ICU收治的无家可归患者与非无家可归患者的临床特征、治疗方法及预后。
方法
随机选取63名无家可归患者，并与63名年龄、性别和收治ICU相匹配的非无家可归患者进行比较。
结果
与匹配的非无家可归患者相比，无家可归患者（平均年龄48±12岁，90%为男性，87%通过救护车收治，56%接受机械通气，急性生理与慢性健康状况评分系统II平均评分为17）除了酒精使用增加（70%对17%，p<0.001）、非法药物使用增加（46%对8%，p<0.001）以及记录在案的高血压（16%对40%，p = 0.005）或处方药使用较少（48%对67%，p<0.05）外，合并症和疾病严重程度相似。ICU干预强度相似，但硫胺素（71%对21%，p<0.0001）和尼古丁（38%对14%，p = 0.004）处方较多。无家可归患者的格拉斯哥昏迷评分显著较低，细菌呼吸道培养阳性率显著更高。抗生素、血管加压药/正性肌力药使用时间、通气时间、ICU住院时间和住院总时长较长，但差异无统计学意义，不过无家可归患者的医院死亡率较高（29%对8%，p = 0.005）。对所有死亡病例的审查发现，两组在类似的临床情况和比例下都出现了维持生命治疗的撤减，无论是否有家属参与。使用多变量逻辑回归分析，无家可归似乎不是医院死亡率的独立预测因素。
结论
与非无家可归患者按年龄和性别匹配（临床医生最常用的特征）收治入ICU的无家可归患者，尽管合并症和疾病严重程度相似，但医院死亡率较高。生命支持时间延长的趋势可能导致了较高的死亡率。需要进一步研究来证实这种较高的死亡率，并制定改善这一弱势群体预后的策略。
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