分阶段实施唤醒和呼吸、协调、谵妄监测和管理以及早期活动套餐可改善患者结局并降低医院成本。
Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs.
机构信息
Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
Division of Pulmonary Diseases, Critical Care, and Environmental Medicine, Department of Medicine, Tulane University School of Medicine, New Orleans, LA.
出版信息
Crit Care Med. 2019 Jul;47(7):885-893. doi: 10.1097/CCM.0000000000003765.
OBJECTIVES
To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost.
DESIGN
Prospective cohort study.
SETTING
Two medical ICUs within Montefiore Healthcare Center (Bronx, NY).
PATIENTS
One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.
INTERVENTIONS
At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).
MEASUREMENTS AND MAIN RESULTS
In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively.
CONCLUSIONS
In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.
目的
衡量分步实施完整 ABCDE 包与部分 ABCDE 包对机械通气时间、重症监护病房（ICU）和住院时间以及成本的影响。
设计
前瞻性队列研究。
地点
Montefiore 医疗保健中心（纽约州布朗克斯）的两个医疗 ICU。
患者
2011 年 7 月至 2014 年 7 月期间入住 ICU 的 1855 名机械通气患者。
干预措施
在基线时，两个 ICU 均正在进行自主呼吸试验（B）；在第 1 期，完整和部分 ABCDE 包 ICU 均实施了（A）觉醒和（D）谵妄（AD）；在第 2 期，完整 ABCDE 包（B-AD-EC）实施了（E）早期动员和结构化包（C）协调（EC），但部分 ABCDE 包 ICU 未实施（B-AD）。
测量和主要结果
在完整 ABCDE 包 ICU，实施 EC 前（第 1 期），95%的患者住院期间卧床。实施 EC 后（第 2 期），65%的患者站立，54%的患者在 ICU 期间至少行走一次，ICU 获得性压疮和身体约束的使用减少（第 1 期与第 2 期：分别有 39%和 23%的患者；分别有 30%和 26%的患者天，p<0.001）。在调整患者水平协变量后，与实施部分（B-AD）包相比，实施完整（B-AD-EC）包与机械通气时间缩短（-22.3%；95%CI，-22.5%至-22.0%；p<0.001）、ICU 住院时间缩短（-10.3%；95%CI，-15.6%至-4.7%；p=0.028）和住院时间缩短（-7.8%；95%CI，-8.7%至-6.9%；p=0.006）相关。ICU 和医院总成本也分别降低了 24.2%（95%CI，-41.4%至-2.0%；p=0.03）和 30.2%（95%CI，-46.1%至-9.5%；p=0.007）。
结论
在临床实践环境中，将（E）早期动员和 ABCDE 包组件的结构化（C）协调添加到自主（B）呼吸、（A）觉醒和（D）谵妄管理背景中，可显著缩短机械通气时间、住院时间和成本。
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