重症监护病房患者容量紧张与死亡率的关系：路径分析建模策略。

Association between strained capacity and mortality among patients admitted to intensive care: A path-analysis modeling strategy.

机构信息

Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-112 ST NW, Edmonton, Alberta, Canada; Alberta Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada.

Research Facilitation, Research Priorities & Implementation, Research Innovation and Analytics, Alberta Health Services, Alberta, Canada.

出版信息

J Crit Care. 2018 Feb;43:81-87. doi: 10.1016/j.jcrc.2017.08.032. Epub 2017 Aug 24.

DOI:10.1016/j.jcrc.2017.08.032

PMID:28854400

Abstract

PURPOSE

To evaluate the associations between strained ICU capacity and patient outcomes.

METHODS

Multi-center population-based cohort study of nine integrated ICUs in Alberta, Canada. Path-analysis modeling was adopted to investigate direct and indirect associations between strain (available beds ≤1; occupancy ≥95%) and outcomes. Mixed-effects multivariate regression was used to measure the association between strain and acuity (APACHE II score), and both acuity and strain measures on ICU mortality and length of stay.

RESULTS

12,265 admissions comprise the study cohort. Available beds ≤1 and occupancy ≥95% occurred for 22.3% and 17.0% of admissions. Lower bed availability was associated with higher APACHE II score (p<0.0001). The direct effect of ≤1 available beds at ICU admission on ICU mortality was 11.6% (OR 1.116; 95% CI, 0.995-1.252). Integrating direct and indirect effects resulted in a 16.5% increased risk of ICU mortality (OR 1.165; 95% CI, 1.036-1.310), which exceeded the direct effect by 4.9%. Findings were similar with strain defined as occupancy ≥95%. Strain was associated with shorter ICU stay, primarily mediated by greater acuity.

CONCLUSIONS

Strained capacity was associated with increased ICU mortality, partly mediated through greater illness acuity. Future work should consider both the direct and indirect relationships of strain on outcomes.

摘要

目的

评估 ICU 容量紧张与患者预后之间的关联。

方法

这是一项在加拿大阿尔伯塔省 9 家综合 ICU 进行的多中心基于人群的队列研究。采用路径分析模型来研究紧张状态（可用床位≤1；入住率≥95%）与结局之间的直接和间接关联。采用混合效应多元回归来衡量紧张状态与严重程度（APACHE II 评分）之间的关联，以及紧张状态和严重程度指标对 ICU 死亡率和住院时间的影响。

结果

该研究纳入了 12265 例入住 ICU 的患者。22.3%和 17.0%的患者存在可用床位≤1 和入住率≥95%的情况。可用床位较少与 APACHE II 评分较高相关（p<0.0001）。入住 ICU 时可用床位≤1 对 ICU 死亡率的直接影响为 11.6%（OR 1.116；95%CI，0.995-1.252）。整合直接和间接效应后，ICU 死亡率的风险增加了 16.5%（OR 1.165；95%CI，1.036-1.310），超过了直接效应的 4.9%。将紧张状态定义为入住率≥95%时，结果相似。紧张状态与 ICU 住院时间缩短有关，主要通过严重程度增加来介导。