创伤重症监护病房的关键决策：我们是否在进行初级姑息治疗？
Critical decisions in the trauma intensive care unit: Are we practicing primary palliative care?
机构信息
From the Department of Surgery (A.E., S.H., E.N.D., T.S., D.Z., K.B., M.R.C., A.K.N.), Oregon Health and Science University; and Operative Care Division (A.K.N.), VA Portland Medical Center, Portland, Oregon.
出版信息
J Trauma Acute Care Surg. 2021 Nov 1;91(5):886-890. doi: 10.1097/TA.0000000000003324.
BACKGROUND
Devastating injuries require both urgent assessment by a trauma service and early attention to patients' goals of care (GOC). American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines recommend an initial palliative assessment within 24 hours of admission and family meeting, if needed, within 72 hours. We hypothesize that a primary palliative care-based practice improves adherence to TQIP guidelines in trauma patients.
METHODS
All adult trauma patients who died while inpatient from January 2014 to December 2018 were reviewed. Timing of GOC discussions, transition to comfort measures only (CMO), and the utilization of specialty palliative services were analyzed with univariate analysis.
RESULTS
During the study period, 415 inpatients died. Median Injury Severity Score was 26 (interquartile range [IQR], 17-34), median age was 67 years (IQR, 51-81 years), and 72% (n = 299) transitioned to CMO before death. Documented GOC discussions increased from 77% of patients in 2014 to 95% of patients in 2018 (p < 0.001), and in 2018, the median time to the first GOC discussion was 15 hours (IQR, 7- 24 hours). Specialty palliative care was consulted in 7% of all patients. Of patients who had at least one GOC discussion, 98% were led by the trauma intensive care unit (TICU) team. Median time from admission to first GOC discussion was 27 hours (IQR, 6-91 hours). Median number of GOC discussions was 1 (IQR, 1-2). Median time to CMO after the final GOC discussion was 0 hours (IQR, 0-3). Median time to death after transition to CMO was 4 hours (IQR, 1-18 hours).
CONCLUSION
Of those who died during index admission, we demonstrated significant improvement in adherence to American College of Surgeons TQIP palliative guidelines across the 5-year study period, with the TICU team guiding the majority of GOC discussions. Our TICU team has developed an effective primary palliative care approach, selectively consulting specialty palliative care only when needed.
LEVEL OF EVIDENCE
Therapeutic/care management, level III.
背景
严重创伤需要创伤服务团队的紧急评估和对患者的照护目标（GOC）的早期关注。美国外科医师学院创伤质量改进计划（TQIP）指南建议在入院后 24 小时内进行初步姑息评估，如果需要，在 72 小时内进行家庭会议。我们假设以姑息治疗为基础的主要治疗方法可提高创伤患者对 TQIP 指南的遵循程度。
方法
回顾了 2014 年 1 月至 2018 年 12 月期间因住院而死亡的所有成年创伤患者。采用单变量分析方法分析了 GOC 讨论的时机、向仅提供舒适护理（CMO）的过渡以及专业姑息治疗服务的利用情况。
结果
在研究期间，415 名住院患者死亡。损伤严重程度评分中位数为 26（四分位距[IQR]，17-34），年龄中位数为 67 岁（IQR，51-81 岁），72%（n=299）在死亡前过渡到 CMO。记录的 GOC 讨论从 2014 年的 77%增加到 2018 年的 95%（p<0.001），并且在 2018 年，首次 GOC 讨论的中位时间为 15 小时（IQR，7-24 小时）。所有患者中有 7%接受了专业姑息治疗。在至少进行了一次 GOC 讨论的患者中，98%由创伤重症监护病房（TICU）团队领导。从入院到首次 GOC 讨论的中位时间为 27 小时（IQR，6-91 小时）。GOC 讨论的中位数次数为 1（IQR，1-2）。最后一次 GOC 讨论后向 CMO 过渡的中位时间为 0 小时（IQR，0-3）。从过渡到 CMO 到死亡的中位时间为 4 小时（IQR，1-18 小时）。
结论
在住院期间死亡的患者中，我们在 5 年的研究期间证明了对美国外科医师学院 TQIP 姑息治疗指南的遵循程度有了显著提高，TICU 团队主导了大多数 GOC 讨论。我们的 TICU 团队已经开发了一种有效的姑息治疗方法，仅在需要时选择性地咨询专业姑息治疗。
证据水平
治疗/护理管理，III 级。
Zotero 插件