重症患者院间转运期间临床病情恶化的发生率及危险因素；一项队列研究。
Incidence and Risk Factors of Clinical Deterioration during Inter-Facility Transfer of Critically Ill Patients; a Cohort Study.
作者信息
Srithong Kannapatch, Sindhu Siriorn, Wanitkun Napaporn, Viwatwongkasem Chukiat
机构信息
DNS candidate, Faculty of Graduate Studies,Mahidol University, Thailand.
RN, PhD, Associate Professor, Department of Surgical nursing, Faculty of Nursing,Mahidol University, Thailand.
出版信息
Arch Acad Emerg Med. 2020 Jul 4;8(1):e65. eCollection 2020.
INTRODUCTION
Critically ill and injured patients are at a higher risk of developing clinical deterioration during inter-facility transfers. This study aimed to determine the incidence rate and risk factors of clinical deterioration among critically ill patients during inter-facility transfers in Thailand.
METHODS
The present cohort study was conducted in 22 referring hospitals and 7 receiving hospitals under the supervision of Ministry of Public Health, Thailand, between March 15 and December 31, 2018. The subjects were comprised of 839 critically ill patients aged 18 and over, 63 coordinator nurses in referral centers, and 312 referral team leaders. Data collected included pre-transfer risk score, clinical data of patient during transfer, characteristics of referral team leader, ambulance type, preparation time, time to definitive care, transfer distance, and National Early Warning Score (NEWS) (clinical deterioration). Multilevel mixed-effects regression analysis was performed.
RESULTS
The incidence rate of clinical deterioration was 28.69%. The most common types of clinical deterioration were hemodynamic instability, respiratory instability, and neurological alteration. Time between 31-45 minutes was significantly associated with clinical deterioration (β 0.133, value 0.027). The following illnesses were associated with higher probability of clinical deterioration: body region injuries/head injury/burn/ingested poison (β 0.670, value 0.030), respiratory distress/convulsion (β 0.919, value 0.001), shock/ arrhythmias/chest pain/hemorrhage (β 1.134, value <0.001), comatose/alteration of consciousness/syncope (β 1.343, value <0.001), and post-cardiac arrest (β 2.251, value <0.001). Patients with unstable conditions (β 1.689, value 0.001) and pre-transfer risk score of 8 or higher (β 0.625, value 0.001) had a higher rate of deterioration. Transfer by non- emergency room (ER) nurses (β 0.495, value 0.008) and transportation in a mobile intensive care unit (ICU) were associated with a higher rate of deterioration (β 0.848, value 0.001).
CONCLUSION
The incidence of clinical deterioration during inter-facility transfer in Thailand was high. Illnesses involving circulatory, respiratory, and neurological systems, clinical instability, high pre-transfer risk score, transport time of 31-45 minutes, transportation by non-ER nurse, and mobile ICU were associated with a higher rate of clinical deterioration.
引言
重症和受伤患者在医疗机构间转运过程中发生临床病情恶化的风险更高。本研究旨在确定泰国重症患者在医疗机构间转运期间临床病情恶化的发生率及风险因素。
方法
本队列研究于2018年3月15日至12月31日在泰国公共卫生部监督下的22家转诊医院和7家接收医院进行。研究对象包括839名18岁及以上的重症患者、转诊中心的63名协调护士以及312名转诊团队负责人。收集的数据包括转运前风险评分、转运期间患者的临床数据、转诊团队负责人的特征、救护车类型、准备时间、确定性治疗时间、转运距离以及国家早期预警评分（NEWS）（临床病情恶化）。进行了多水平混合效应回归分析。
结果
临床病情恶化的发生率为28.69%。临床病情恶化最常见的类型是血流动力学不稳定、呼吸不稳定和神经功能改变。31 - 45分钟之间的时间与临床病情恶化显著相关（β 0.133，P值0.027）。以下疾病与临床病情恶化的较高概率相关：身体部位损伤/头部损伤/烧伤/中毒（β 0.670，P值0.030）、呼吸窘迫/惊厥（β 0.919，P值0.001）、休克/心律失常/胸痛/出血（β 1.134，P值<0.001）、昏迷/意识改变/晕厥（β 1.343，P值<0.001）以及心脏骤停后（β 2.251，P值<0.001）。病情不稳定的患者（β 1.689，P值0.001）和转运前风险评分为8分或更高的患者（β 0.625，P值0.001）病情恶化率更高。由非急诊室（ER）护士进行转运（β 0.495，P值0.008）以及在移动重症监护病房（ICU）进行转运与更高的病情恶化率相关（β 0.848，P值0.001）。
结论
泰国医疗机构间转运期间临床病情恶化发生率较高。涉及循环、呼吸和神经系统的疾病、临床不稳定、转运前风险评分高、31 - 45分钟的转运时间、非ER护士转运以及移动ICU与更高的临床病情恶化率相关。
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