Division of Pulmonary, Allergy, and Critical Care.
Palliative and Advanced Illness Research Center.
Ann Am Thorac Soc. 2020 Dec;17(12):1599-1609. doi: 10.1513/AnnalsATS.201912-912OC.
A small but growing number of hospitals are experimenting with emergency department-embedded critical care units (CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF). To evaluate the potential impact of an emergency department-embedded CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the emergency department to a medical ward or intensive care unit (ICU) from January 2016 to December 2017. The exposure was eligibility for admission to the emergency department-embedded CCU, which was defined as meeting a clinical definition for sepsis or ARF and admission to the emergency department during the intervention period on a weekday. The primary outcome was hospital length of stay (LOS); secondary outcomes included total emergency department plus ICU LOS, hospital survival, direct admission to the ICU, and unplanned ICU admission. Primary interrupted time series analyses were performed using ordinary least squares regression comparing monthly means. Secondary retrospective cohort and before-after analyses used multivariable Cox proportional hazard and logistic regression. In the baseline and intervention periods, 3,897 patients met the inclusion criteria for sepsis and 1,865 patients met the criteria for ARF. Among patients admitted with sepsis, opening of the emergency department-embedded CCU was not associated with hospital LOS (β = -1.82 d; 95% confidence interval [CI], -4.50 to 0.87; = 0.17 for the first month after emergency department-embedded CCU opening compared with baseline; β = -0.26 d; 95% CI, -0.58 to 0.06; = 0.10 for subsequent months). Among patients admitted with ARF, the emergency department-embedded CCU was not associated with a significant change in hospital LOS for the first month after emergency department-embedded CCU opening (β = -3.25 d; 95% CI, -7.86 to 1.36; = 0.15) but was associated with a 0.64 d/mo shorter hospital LOS for subsequent months (β = -0.64 d; 95% CI, -1.12 to -0.17; = 0.01). This result persisted among higher acuity patients requiring ventilatory support but was not supported by alternative analytic approaches. Among patients admitted with sepsis who did not require mechanical ventilation or vasopressors in the emergency department, the emergency department-embedded CCU was associated with an initial 9.9% reduction in direct ICU admissions in the first month (β = -0.099; 95% CI, -0.153 to -0.044; = 0.002), followed by a 1.1% per month increase back toward baseline in subsequent months (β = 0.011; 95% CI, 0.003-0.019; = 0.009). This relationship was supported by alternative analytic approaches and was not seen in ARF. No associations with emergency department plus ICU LOS, hospital survival, or unplanned ICU admission were observed among patients with sepsis or ARF. The emergency department-embedded CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick patients with sepsis, the emergency department-embedded CCU was initially associated with reduced rates of direct ICU admission from the emergency department. Additional research is necessary to further evaluate the impact and utility of the emergency department-embedded CCU model.
一家小医院，在急诊部设立了重症监护室（CCU），以提高患有脓毒症和急性呼吸衰竭（ARF）的重病患者的护理质量。为了评估宾夕法尼亚大学医院急诊部嵌入 CCU 的潜在影响，在 2016 年 1 月至 2017 年 12 月期间，从急诊部转入内科病房或 ICU 的脓毒症和 ARF 患者中，评估急诊部嵌入 CCU 的效果。暴露的标准是符合脓毒症或 ARF 的临床定义，并在干预期间的工作日到急诊部就诊。主要结果是住院时间（LOS）；次要结果包括急诊部加 ICU 的 LOS、医院存活率、直接入住 ICU 和计划外 ICU 入院。使用普通最小二乘法回归比较每月平均值进行主要的中断时间序列分析。二次回顾性队列和前后分析使用多变量 Cox 比例风险和逻辑回归。在基线和干预期间，3897 名患者符合脓毒症的纳入标准，1865 名患者符合 ARF 的标准。在因脓毒症而入院的患者中，急诊部嵌入 CCU 的开设与医院 LOS 无关（β=-1.82 d；95%CI，-4.50 至 0.87；与基线相比，急诊部嵌入 CCU 开设后的第一个月的=0.17；β=-0.26 d；95%CI，-0.58 至 0.06；与后续月份相比，=0.10）。在因 ARF 而入院的患者中，急诊部嵌入 CCU 开设后的第一个月，医院 LOS 没有显著变化（β=-3.25 d；95%CI，-7.86 至 1.36；=0.15），但随后几个月的医院 LOS 缩短了 0.64 d/月（β=-0.64 d；95%CI，-1.12 至-0.07；=0.01）。这一结果在需要通气支持的更高危患者中仍然存在，但替代分析方法并不支持这一结果。在因脓毒症而入院且在急诊部不需要机械通气或血管加压素的患者中，急诊部嵌入 CCU 在第一个月直接 ICU 入院率降低了 9.9%（β=-0.099；95%CI，-0.153 至-0.044；=0.002），随后在后续几个月中，每月增加 1.1%，回到基线（β=0.011；95%CI，0.003-0.019；=0.009）。这一关系得到了替代分析方法的支持，在 ARF 中并未观察到。在脓毒症或 ARF 患者中，与急诊部加 ICU 的 LOS、医院存活率或计划外 ICU 入院均无关联。在因脓毒症或 ARF 而入院的患者中，急诊部嵌入 CCU 与临床结局无关。在病情较轻的脓毒症患者中，急诊部嵌入 CCU 最初与直接从急诊部转入 ICU 的比例降低有关。需要进一步研究以进一步评估急诊部嵌入 CCU 模式的影响和实用性。
