Clinical Ethics, Institute of History and Ethics in Medicine, Technical University of Munich, School of Medicine, Munich, Germany.
Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany.
Crit Care Med. 2022 Dec 1;50(12):1714-1724. doi: 10.1097/CCM.0000000000005684. Epub 2022 Oct 12.
Simulation and evaluation of a prioritization protocol at a German university hospital using a convergent parallel mixed methods design.
Prospective single-center cohort study with a quantitative analysis of ICU patients and qualitative content analysis of two focus groups with intensivists.
Five ICUs of internal medicine and anesthesiology at a German university hospital.
Adult critically ill ICU patients ( n = 53).
After training the attending senior ICU physicians ( n = 13) in rationing, an impending ICU congestion was simulated. All ICU patients were rated according to their likelihood to survive their acute illness (good-moderate-unfavorable). From each ICU, the two patients with the most unfavorable prognosis ( n = 10) were evaluated by five prioritization teams for triage.
Patients nominated for prioritization visit ( n = 10) had higher Sequential Organ Failure Assessment scores and already a longer stay at the hospital and on the ICU compared with the other patients. The order within this worst prognosis group was not congruent between the five teams. However, an in-hospital mortality of 80% confirmed the reasonable match with the lowest predicted probability of survival. Qualitative data highlighted the tremendous burden of triage and the need for a team-based consensus-oriented decision-making approach to ensure best possible care and to support professionals. Transparent communication within the teams, the hospital, and to the public was seen as essential for prioritization implementation.
To mitigate potential bias and to reduce the emotional burden of triage, a consensus-oriented, interdisciplinary, and collaborative approach should be implemented. Prognostic comparative assessment by intensivists is feasible. The combination of long-term ICU stay and consistently high Sequential Organ Failure Assessment scores resulted in a greater risk for triage in patients. It remains challenging to reliably differentiate between patients with very low chances to survive and requires further conceptual and empirical research.
使用收敛并行混合方法设计，模拟和评估德国大学医院的优先级协议。
前瞻性单中心队列研究，对 ICU 患者进行定量分析，对 2 个内科和麻醉学重症监护病房的集中小组进行定性内容分析。
德国一所大学医院的 5 个内科和麻醉学重症监护病房。
成人危重症 ICU 患者（n = 53）。
在对主治高级 ICU 医生（n = 13）进行配给培训后，模拟了即将发生的 ICU 拥堵。根据他们存活急性疾病的可能性（良好-中度-不良）对所有 ICU 患者进行评分。从每个 ICU 中，根据五个优先级团队的评估，对预后最差的两名患者（n = 10）进行分诊。
被提名进行优先级访问的患者（n = 10）的序贯器官衰竭评估评分较高，且与其他患者相比，他们在医院和 ICU 的停留时间更长。在这个预后最差的患者组中，五个团队之间的顺序并不一致。然而，住院死亡率为 80%，证实了与最低预测生存率的合理匹配。定性数据突出了分诊的巨大负担，需要采用基于团队的共识导向决策方法，以确保提供最佳护理，并支持专业人员。团队内部、医院和公众之间的透明沟通被视为实施优先级的关键。
为了减轻潜在的偏见和减少分诊的情绪负担，应采用共识导向的、跨学科的和协作的方法。重症监护医生进行预后比较评估是可行的。长期 ICU 停留和持续高序贯器官衰竭评估评分导致患者分诊风险增加。可靠地区分存活机会极低的患者仍然具有挑战性，需要进一步进行概念和实证研究。
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