侵入性操作前“不要复苏”医嘱的管理
Management of Do Not Resuscitate Orders Before Invasive Procedures.
作者信息
Wong Jennifer, Gravely Amy, Duane Peter G
机构信息
is an Instructor, and is an Associate Professor, both at the University of Minnesota in Minneapolis. is a Research Service Biostatistician, and Peter Duane is an Associate Director of the Primary and Specialty Care Service Line in the Division of Pulmonary and Critical Care, both at the Minneapolis Veterans Affairs Health Care System.
出版信息
Fed Pract. 2021 Feb;38(2):80-83. doi: 10.12788/fp.0088.
BACKGROUND
In 2017, the US Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI), which created a portable and durable code status for use across its health care system. Patients who now have a durable do not resuscitate (DNR) status may undergo invasive procedures. Few studies have examined whether proceduralists discuss DNR status and document changes before procedures.
OBJECTIVE
To assess baseline percentage of suspension of DNR before nonsurgical invasive procedures and determine whether an academic detailing intervention consisting of training proceduralists in the use of a template that allows rapid suspension of DNR status increases percentage of DNR acknowledgments.
METHODS
Single-center, quasi-experimental pre- and postassessments were done in high-volume, procedural areas, including gastroenterology, cardiology, and interventional radiology, in a VA medical center. The primary outcome was the proceduralists' documentation of DNR status acknowledgment before a nonsurgical invasive procedure at baseline and after the intervention. Logistic regression was used to compare percentage of DNR acknowledgment with time (before, after) and procedural area and assessing their interaction in the model.
RESULTS
The interaction between department and time revealed wide variation in documentation of DNR acknowledgment. Examining the model predicted percentages from the interaction, preintervention percentages for gastroenterology, cardiology and interventional radiology were 46%, 75.6%, and 7.5%, respectively, and postintervention model predicted percentages were 53.5%, 91.7%, and 26.3%, respectively. Only the before vs after contrast for interventional radiology was significantly different. When all procedural areas were combined, the percentage of DNR acknowledgment significantly improved from 38.6% to 61.1% ( = .01).
CONCLUSIONS
Before nonsurgical invasive procedures, the percentage of DNR acknowledgment was low but after, the intervention significantly improved. Further research is needed to assess its impact on patient-centered outcomes.
背景
2017年，美国退伍军人事务部（VA）实施了维持生命治疗决策倡议（LSTDI），该倡议创建了一种便携式且持久的代码状态，以便在其医疗系统中使用。现在拥有持久的“不要复苏”（DNR）状态的患者可能会接受侵入性手术。很少有研究探讨手术医生在手术前是否讨论过DNR状态并记录相关变化。
目的
评估非手术侵入性手术前DNR暂停的基线百分比，并确定一项学术详细指导干预措施（包括培训手术医生使用允许快速暂停DNR状态的模板）是否会提高DNR确认的百分比。
方法
在一家VA医疗中心的高流量手术科室，包括胃肠病学、心脏病学和介入放射学，进行了单中心、准实验性的前后评估。主要结果是手术医生在基线和干预后非手术侵入性手术前对DNR状态确认的记录。采用逻辑回归比较DNR确认百分比与时间（之前、之后）和手术科室的关系，并评估它们在模型中的相互作用。
结果
科室与时间之间的相互作用显示，DNR确认记录存在很大差异。通过检查模型根据相互作用预测的百分比，胃肠病学、心脏病学和介入放射学干预前的百分比分别为46%、75.6%和7.5%，干预后模型预测的百分比分别为53.5%、91.7%和26.3%。只有介入放射学的干预前后对比有显著差异。当所有手术科室合并时，DNR确认的百分比从38.6%显著提高到61.1%（P = 0.01）。
结论
在非手术侵入性手术前，DNR确认的百分比很低，但在干预后显著提高。需要进一步研究以评估其对以患者为中心的结果的影响。
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