Lekwijit Suparerk, Chan Carri W, Green Linda V, Liu Vincent X, Escobar Gabriel J
Operations, Information and Decisions Department, The Wharton School, University of Pennsylvania, Philadelphia, PA.
Decision, Risk and Operations Division, Columbia Business School, New York, NY.
Crit Care Explor. 2020 May 6;2(5):e0114. doi: 10.1097/CCE.0000000000000114. eCollection 2020 May.
To examine whether and how step-down unit admission after ICU discharge affects patient outcomes.
Retrospective study using an instrumental variable approach to remove potential biases from unobserved differences in illness severity for patients admitted to the step-down unit after ICU discharge.
Ten hospitals in an integrated healthcare delivery system in Northern California.
Eleven-thousand fifty-eight episodes involving patients who were admitted via emergency departments to a medical service from July 2010 to June 2011, were admitted to the ICU at least once during their hospitalization, and were discharged from the ICU to the step-down unit or the ward.
None.
Using congestion in the step-down unit as an instrumental variable, we quantified the impact of step-down unit care in terms of clinical and operational outcomes. On average, for ICU patients with lower illness severity, we found that availability of step-down unit care was associated with an absolute decrease in the likelihood of hospital readmission within 30 days of 3.9% (95% CI, 3.6-4.1%). We did not find statistically significant effects on other outcomes. For ICU patients with higher illness severity, we found that availability of step-down unit care was associated with an absolute decrease in in-hospital mortality of 2.5% (95% CI, 2.3-2.6%), a decrease in remaining hospital length-of-stay of 1.1 days (95% CI, 1.0-1.2 d), and a decrease in the likelihood of ICU readmission within 5 days of 3.6% (95% CI, 3.3-3.8%).
This study shows that there exists a subset of patients discharged from the ICU who may benefit from care in an step-down unit relative to that in the ward. We found that step-down unit care was associated with statistically significant improvements in patient outcomes especially for high-risk patients. Our results suggest that step-down units can provide effective transitional care for ICU patients.
探讨重症监护病房（ICU）出院后转入逐步降级护理病房是否以及如何影响患者的治疗结果。
一项回顾性研究，采用工具变量法以消除ICU出院后转入逐步降级护理病房患者未观察到的疾病严重程度差异所带来的潜在偏差。
北加利福尼亚一个综合医疗服务系统中的十家医院。
2010年7月至2011年6月期间，11058例通过急诊科入住内科的患者，住院期间至少入住过一次ICU，且从ICU转出至逐步降级护理病房或普通病房。
无。
以逐步降级护理病房的拥挤程度作为工具变量，我们从临床和运营结果方面量化了逐步降级护理病房护理的影响。平均而言，对于病情较轻的ICU患者，我们发现逐步降级护理病房护理的可及性与30天内再次入院可能性的绝对降低3.9%相关（95%置信区间，3.6 - 4.1%）。我们未发现对其他结果有统计学显著影响。对于病情较重的ICU患者，我们发现逐步降级护理病房护理的可及性与住院死亡率绝对降低2.5%相关（95%置信区间，2.3 - 2.6%），剩余住院天数减少1.1天（95%置信区间，1.0 - 1.2天），以及5天内再次入住ICU可能性降低3.6%相关（95%置信区间，3.3 - 3.8%）。
本研究表明，存在一部分从ICU出院的患者，相对于普通病房护理，他们可能从逐步降级护理病房护理中获益。我们发现逐步降级护理病房护理与患者治疗结果的统计学显著改善相关，尤其是对高危患者。我们的结果表明，逐步降级护理病房可为ICU患者提供有效的过渡性护理。
