重症监护病房出院后护理问题和死亡可避免性：一项多中心回顾性病历研究。
Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study.
机构信息
Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
National Institute for Health Research Biomedical Research Centre, Oxford, UK.
出版信息
Crit Care. 2021 Jan 6;25(1):10. doi: 10.1186/s13054-020-03420-5.
BACKGROUND
Over 138,000 patients are discharged to hospital wards from intensive care units (ICUs) in England, Wales and Northern Ireland annually. More than 8000 die before leaving hospital. In hospital-wide populations, 6.7-18% of deaths have some degree of avoidability. For patients discharged from ICU, neither the proportion of avoidable deaths nor the reasons underlying avoidability have been determined. We undertook a retrospective case record review within the REFLECT study, examining how post-ICU ward care might be improved.
METHODS
A multi-centre retrospective case record review of 300 consecutive post-ICU in-hospital deaths, between January 2015 and March 2018, in 3 English hospitals. Trained multi-professional researchers assessed the degree to which each death was avoidable and determined care problems using the established Structured Judgement Review method.
RESULTS
Agreement between reviewers was good (weighted Kappa 0.77, 95% CI 0.64-0.88). Discharge from an ICU for end-of-life care occurred in 50/300 patients. Of the remaining 250 patients, death was probably avoidable in 20 (8%, 95% CI 5.0-12.1) and had some degree of avoidability in 65 (26%, 95% CI 20.7-31.9). Common problems included out-of-hours discharge from ICU (168/250, 67.2%), suboptimal rehabilitation (167/241, 69.3%), absent nutritional planning (76/185, 41.1%) and incomplete sepsis management (50/150, 33.3%).
CONCLUSIONS
The proportion of deaths in hospital with some degree of avoidability is higher in patients discharged from an ICU than reported in hospital-wide populations. Extrapolating our findings suggests around 550 probably avoidable deaths occur annually in hospital following ICU discharge in England, Wales and Northern Ireland. This avoidability occurs in an elderly frail population with complex needs that current strategies struggle to meet. Problems in post-ICU care are rectifiable but multi-disciplinary.
TRIAL REGISTRATION
ISRCTN14658054.
背景
每年有超过 138000 名患者从英格兰、威尔士和北爱尔兰的重症监护病房（ICU）出院到病房。超过 8000 人在离开医院之前死亡。在全院范围内，6.7-18%的死亡有一定程度的可避免性。对于从 ICU 出院的患者，无论是可避免死亡的比例还是可避免性的根本原因都没有确定。我们在 REFLECT 研究中进行了一项回顾性病例记录回顾，以检查如何改善 ICU 后病房护理。
方法
对 2015 年 1 月至 2018 年 3 月期间，在英国 3 家医院的 300 例连续 ICU 院内死亡患者进行了多中心回顾性病例记录回顾。经过培训的多专业研究人员使用既定的结构化判断审查方法评估了每例死亡的可避免程度，并确定了护理问题。
结果
审查员之间的一致性很好（加权 Kappa 0.77，95%CI 0.64-0.88）。50/300 名患者因临终关怀而从 ICU 出院。在其余 250 名患者中，20 名（8%，95%CI 5.0-12.1）的死亡可能是可以避免的，65 名（26%，95%CI 20.7-31.9）有一定程度的可避免性。常见的问题包括 ICU 下班后出院（250 例中的 168 例，67.2%）、康复不佳（241 例中的 167 例，69.3%）、缺乏营养计划（185 例中的 76 例，41.1%）和脓毒症管理不完整（150 例中的 50 例，33.3%）。
结论
从 ICU 出院的患者中，有一定程度可避免性的死亡比例高于全院范围内报告的死亡比例。推断我们的发现表明，在英格兰、威尔士和北爱尔兰，每年约有 550 例 ICU 出院后在医院内可能发生可避免的死亡。这种可避免性发生在一个老年体弱、需求复杂的人群中，目前的策略难以满足。ICU 后护理中的问题是可以纠正的，但需要多学科合作。
试验注册
ISRCTN83523624。
Zotero 插件