Department of Critical Care Medicine, CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA.
College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX.
Med Care. 2021 Jul 1;59(7):597-603. doi: 10.1097/MLR.0000000000001531.
Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models.
We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs.
Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes.
The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay.
The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay.
Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.
儿科重症监护病房（PICU）越来越多地配备了高级实践提供者（APP），以补充传统的医师人员配备模式。
我们评估美国 PICU 中包含 APP 的人员配备模式对临床结果和资源利用的影响。
使用医疗保健成本和利用项目州住院数据库，对 2016 年 9 个州 PICU 收治的儿童进行回顾性队列研究。使用同期人员配备调查评估 PICU 人员配备模式。我们使用多变量回归来检查有无 APP 的人员配备模式与结果之间的关联。
主要结局是院内死亡率。次要结局包括医院获得性疾病和 ICU 及医院住院时间的比值比。
样本包括 40 个 PICU 中的 38788 名儿童。与仅配备医师的 PICU 相比，接受包含 APP 的人员配备的 PICU 入院的儿童年龄更小（6.1±5.9 岁 vs. 7.1±6.2 岁），更有可能患有复杂的慢性疾病（64% vs. 43%）和入院时器官衰竭（25% vs. 22%）。两种 PICU 类型之间的死亡率无差异[校正比值比（AOR）：1.23，95%置信区间（CI）：0.83-1.81，P=0.30]。接受包含 APP 的人员配备的 PICU 患儿发生中心静脉相关血流感染的可能性较低（AOR：0.76，95%CI：0.59-0.98，P=0.03）和导管相关尿路感染的可能性较低（AOR：0.73，95%CI：0.61-0.86，P<0.001）。住院时间无差异。
尽管年龄更小、病情更重，但与仅配备医师的 PICU 相比，接受包含 APP 的人员配备的 PICU 患儿的死亡率无增加，且某些医院获得性疾病的发生率较低。进一步的研究可以为优化结果的 APP 整合策略提供信息。
