采用结构化判断审查方法，研究治疗升级/限制计划对患者在住院死亡前最后一次住院期间的非有益干预措施及伤害的影响。
Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method.
作者信息
Lightbody Calvin J, Campbell Jonathan N, Herbison G Peter, Osborne Heather K, Radley Alice, Taylor D Robin
机构信息
Department of Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, UK.
Department of Medicine,, University Hospital Wishaw, NHS Lanarkshire, Wishaw, UK.
出版信息
BMJ Open. 2018 Oct 31;8(10):e024264. doi: 10.1136/bmjopen-2018-024264.
OBJECTIVES
To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.
DESIGN
A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance.
SETTING
Medical, surgical and intensive care units of a district general hospital.
OUTCOMES
The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method.
RESULTS
289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).
CONCLUSIONS
The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.
目的
评估使用治疗升级/限制计划（TELP）对300例入院后死亡患者伤害发生频率的影响。
设计
对300例未经挑选的连续死亡病例进行回顾性病例记录审查，包括：（1）除了不进行心肺复苏医嘱（DNACPR）外还拥有TELP的患者；（2）仅拥有DNACPR的患者；（3）两者都没有的患者。使用金标准框架预后指标指南将患者死亡情况回顾性分类为“预期”或“意外”。
地点
一家地区综合医院的内科、外科和重症监护病房。
结果
主要结果是使用结构化判断审查方法确定的伤害发生率、非有益干预（NBI）和临床“问题”在组间的差异。
结果
289份病例记录可评估。155例拥有TELP和DNACPR（54%）；113例仅拥有DNACPR（39%）；21例两者都没有（7%）。247例死亡（86%）为“预期”死亡。在“预期”死亡患者中，以拥有TELP/DNACPR的患者作为对照（发病率比（IRR）=1.00），IRR分别为：伤害方面，2.99（仅拥有DNACPR）和4.00（既没有TELP也没有DNACPR）（两者p<0.001）；NBI方面，相应的IRR分别为2.23（仅拥有DNACPR）和2.20（两者都没有）（分别为p<0.001和p<0.005）；“问题”方面，2.30（仅拥有DNACPR）和2.76（两者都没有）（两者p<0.001）。与“仅拥有DNACPR”组和“两者都没有”组相比，拥有TELP/DNACPR组的伤害、NBI和“问题”发生率显著更低：伤害（每1000个床日）分别为17.1、76.9（p<0.001）和197.8（p<0.001）；NBI分别为27.4、92.1（p<0.001）和172.4（p<0.001）；“问题”分别为42.3、146.2（p<0.01）和333.3（p<0.001）。
结论
使用TELP与急性入院后死亡患者的伤害、NBI和“问题”显著减少相关，尤其是对于那些可能处于生命最后一年的患者。
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