急诊患者危急病情识别延迟的预测因素及其对发病率和死亡率的影响。

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality.

机构信息

Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Northwell Health, 232890Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.

出版信息

J Intensive Care Med. 2022 Jan;37(1):52-59. doi: 10.1177/0885066620967901. Epub 2020 Oct 29.

DOI:10.1177/0885066620967901

PMID:33118840

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC8081733/

Abstract

PURPOSE

Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition.

METHODS

We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition.

RESULTS

Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload.

CONCLUSIONS

Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

摘要

目的

及时识别危重病与改善预后相关，但依赖于准确的分诊，而分诊受工作量和人员配备等系统因素的影响。我们首先研究了在控制系统因素后，延迟识别对患者预后的影响，然后确定了延迟识别的潜在预测因素。

方法

我们对直接从急诊科或急诊科出院后 48 小时内转入重症监护病房（ICU）的急诊科患者进行了回顾性队列研究。通过电子和标准化图表摘要获得队列特征。使用人口普查数据估计急诊科工作量和容量的操作指标与患者的急诊科停留时间相匹配。危重病的延迟识别定义为急诊科没有进行 ICU 咨询或 ICU 团队拒绝 ICU 入院。我们采用熵平衡多变量模型来研究延迟识别与持续器官功能障碍和/或住院 28 天（POD+D）后死亡的发展之间的关联，并采用多变量回归模型来确定与延迟识别相关的因素。

结果

延迟识别的患者 POD+D 增加（OR 1.82，95%CI 1.13-2.92）。当 ICU 团队做出延迟识别时，与要求 ICU 咨询并接受入院的患者相比，患者发生 POD+D 的可能性增加了 2.61 倍。初始严重程度评分较低（OR 0.26，95%CI 0.12-0.53）是延迟识别的预测因素。与工作量较低时相比，当 ED 工作量较高时（OR 0.45，95%CI 0.23-0.89），延迟识别的可能性降低。