Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea.
Intensive Care Nursing Team, Ulsan University Hospital, Ulsan, Korea.
J Korean Med Sci. 2020 Jan 20;35(3):e19. doi: 10.3346/jkms.2020.35.e19.
Medical staff members are concentrated in the intensive care unit (ICU), and medical residents are essentially needed to operate the ICU. However, the recent trend has been to restrict resident working hours. This restriction may lead to a shortage of ICU staff, and there is a chance that regional academic hospitals will face running ICUs without residents in the near future.
We performed a retrospective observational study (intensivist crossover design) of medical patients who were transferred to two ICUs from general wards between September 2017 and February 2019 at one academic hospital. We compared the ICU outcomes according to the ICU type (ICU with resident management under high-intensity intensivist staffing vs. ICU with direct management by intensivists without residents).
Of 314 enrolled patients, 70 were primarily managed by residents, and 244 were directly managed by intensivists. The latter patients showed better ICU mortality (29.9% vs. 42.9%, = 0.042), lower cardiopulmonary resuscitation (CPR) (10.2% vs. 21.4%, = 0.013), lower continuous renal replacement therapy (CRRT) (24.2% vs. 40.0%, = 0.009), and more advanced care planning decisions before death (87.3% vs. 66.7%, = 0.013) than the former patients. The better ICU mortality (hazard ratio, 1.641; = 0.035), lower CPR (odds ratio [OR], 2.891; = 0.009), lower CRRT (OR, 2.602; = 0.005), and more advanced care planning decisions before death (OR, 4.978; = 0.007) were also associated with intensivist direct management in the multivariate cox and logistic regression analysis.
Intensivist direct management might be associated with better ICU outcomes than resident management under the supervision of an intensivist. Further large-scale prospective randomized trials are required to draw a definitive conclusion.
医护人员集中在重症监护病房（ICU），而 ICU 的运作基本需要住院医师。然而，最近的趋势是限制住院医师的工作时间。这种限制可能导致 ICU 工作人员短缺，在不久的将来，地区性学术医院有可能在没有住院医师的情况下运行 ICU。
我们对 2017 年 9 月至 2019 年 2 月期间一家学术医院从普通病房转入两个 ICU 的患者进行了回顾性观察研究（ intensivist 交叉设计）。我们根据 ICU 类型（有住院医师管理的 ICU，高强度 intensivist 人员配备；直接由 intensivist 管理的 ICU，无住院医师）比较了 ICU 结果。
在纳入的 314 名患者中，有 70 名患者主要由住院医师管理，244 名患者由 intensivist 直接管理。后者 ICU 死亡率（29.9%比 42.9%， = 0.042）、心肺复苏（CPR）（10.2%比 21.4%， = 0.013）、连续肾脏替代治疗（CRRT）（24.2%比 40.0%， = 0.009）和死亡前更先进的治疗计划决策（87.3%比 66.7%， = 0.013）均优于前者。多变量 Cox 和 logistic 回归分析显示，更好的 ICU 死亡率（风险比，1.641； = 0.035）、更低的 CPR（比值比 [OR]，2.891； = 0.009）、更低的 CRRT（OR，2.602； = 0.005）和更先进的死亡前治疗计划决策（OR，4.978； = 0.007）与 intensivist 直接管理有关。
与住院医师在 intensivist 监督下的管理相比，intensivist 直接管理可能与更好的 ICU 结局相关。需要进一步的大规模前瞻性随机试验来得出明确的结论。
