Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine.
Leonard Davis Institute of Health Economics.
Ann Am Thorac Soc. 2023 Mar;20(3):406-413. doi: 10.1513/AnnalsATS.202205-429OC.
We have previously shown that hospital strain is associated with intensive care unit (ICU) admission and that ICU admission, compared with ward admission, may benefit certain patients with acute respiratory failure (ARF). To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. There was significant among-hospital variation in ICU admission rates, in hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF ( = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared with the ward, but among the 27 hospitals ( = 224-3,324), this effect varied from 5.85 days shorter (95% confidence interval [CI], -8.84 to -2.86; < 0.001) to 4.38 days longer (95% CI, 1.86-6.90; = 0.001). Corresponding ranges for in-hospital mortality with ICU compared with ward admission revealed odds ratios from 0.08 (95% CI, 0.01-0.56; < 0.007) to 8.89 (95% CI, 1.60-79.85; = 0.016) among patients with ARF (pooled odds ratio, 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.
我们之前已经表明，医院压力与重症监护病房（ICU）入院有关，与普通病房入院相比，ICU 入院可能对某些急性呼吸衰竭（ARF）患者有益。为了了解 ARF 患者的压力-过程-结果关系在医院之间可能如何变化，以及医院实践差异可能如何解释这种变化。我们检查了 2013 年至 2018 年间在美国 27 家医院急诊科（ED）无需机械通气或升压药的高急症 ARF 患者，这些患者在 ED 被收治入院。按医院分层，我们比较了医院压力与 ICU 入院的关系，以及 ICU 入院与患者住院时间（LOS）和死亡率之间的关系，这些患者最初被收入 ICU 与普通病房相比。我们还调查了医院的实践情况，并在探索性分析中，评估了这些实践与上述过程和结果的关联。在 ICU 入院率、医院压力与 ICU 入院的关系以及 ICU 入院与医院 LOS 和死亡率的关系方面，医院之间存在显著的差异。总体而言，与普通病房入院相比，ED 中患有 ARF（ = 45339 名）的患者如果最初被收入 ICU，其平均住院 LOS 会缩短 0.82 天，但在 27 家医院（ = 224-3324 名）中，这种效果从缩短 5.85 天（95%置信区间 [CI]，-8.84 至 -2.86； < 0.001）到延长 4.38 天（95%CI，1.86-6.90； = 0.001）不等。与普通病房入院相比，ICU 入院的住院死亡率相应范围为 0.08（95%CI，0.01-0.56； < 0.007）至 8.89（95%CI，1.60-79.85； = 0.016），患有 ARF 的患者的总体比值比为 0.75（ pooled odds ratio，0.75）。在探索性分析中，只有少数测量的医院实践-脓毒症 ED 处置指南的存在和 ED 患者最大容量-可能与医院压力与 ICU 入院的关系有关。医院在 ICU 入院率、这些入院率对医院容量压力的敏感性以及对 ED 中无需生命支持治疗的 ARF 患者 ICU 入院的益处方面差异很大。需要进一步研究以更充分地确定导致这些关系的医院层面因素。
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