时机至关重要：创伤患者早期与晚期姑息治疗会诊对比
Timing is everything: Early versus late palliative care consults in trauma.
作者信息
Spencer Audrey L, Miller Preston R, Russell Gregory B, Cornea Isabella, Marterre Buddy
机构信息
From the Department of Surgery, Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, College of Medicine (A.L.S.), University of Arizona, Tucson, Arizona; Departments of Surgery and Internal Medicine, Atrium Health Wake Forest Baptist (P.R.M., G.B.R., I.C., B.M.), Winston-Salem, NC.
出版信息
J Trauma Acute Care Surg. 2023 May 1;94(5):652-658. doi: 10.1097/TA.0000000000003881. Epub 2022 Dec 25.
BACKGROUND
The incorporation of dedicated palliative care (PC) services in the care of the critically injured trauma patient is not yet universal. Preexisting data demonstrate both economic and clinical value of PC consults, yet patient selection and optimal timing of these consults are poorly defined, possibly leading to underutilization of PC services. Prior studies in geriatric patients have shown benefits of PC when PC clinicians are engaged earlier during hospitalization. We aim to compare hospitalization metrics of early versus late PC consultation in trauma patients.
METHODS
All patients 18 years or older admitted to the trauma service between January 1, 2019, and March 31, 2021, who received a PC consult were included. Patients were assigned to EARLY (PC consult ≤3 days after admission) and LATE (PC consult >3 days after admission) cohorts. Demographics, injury and underlying disease characteristics, outcomes, and financial data were compared. Length of stay (LOS) in the EARLY group is compared with LOS-3 in the LATE group.
RESULTS
A total of 154 patient records met the inclusion criteria (60 EARLY and 94 LATE). Injury Severity Score, head Abbreviated Injury Scale score, and medical comorbidities (congestive heart failure, dementia, previous stroke, chronic obstructive pulmonary disease, malignancy) were similar between the groups. The LATE group was younger (69.9 vs. 75.3, p = 0.04). Patients in the LATE group had significantly longer LOS (17.5 vs. 7.0 days, p < 0.01) and higher median hospital costs ($53,165 vs. $17,654, p < 0.01). Patients in the EARLY group had reduced ventilator days (2.4 vs. 7.0, p < 0.01) and reduced rates of tracheostomies and surgical feeding tubes (1.7% vs. 11.7%, p = 0.03).
CONCLUSION
Trauma patients with early PC consultation had shorter LOS, reduced ventilator days, reduced rates of invasive procedures, and lower costs even after correcting for delay to consult in the late group. These findings suggest the need for mechanisms leading to earlier PC consult in critically injured patients.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level IV.
背景
在重症创伤患者的护理中纳入专门的姑息治疗（PC）服务尚未普及。既往数据表明了PC会诊的经济和临床价值，但患者选择以及这些会诊的最佳时机定义不明确，这可能导致PC服务利用不足。先前针对老年患者的研究表明，当PC临床医生在住院期间更早介入时，PC会带来益处。我们旨在比较创伤患者早期与晚期PC会诊的住院指标。
方法
纳入2019年1月1日至2021年3月31日期间入住创伤科且接受PC会诊的所有18岁及以上患者。患者被分为早期组（入院后≤3天接受PC会诊）和晚期组（入院后>3天接受PC会诊）。比较人口统计学、损伤和基础疾病特征、结局及财务数据。将早期组的住院时间（LOS）与晚期组的LOS - 3进行比较。
结果
共有154份患者记录符合纳入标准（早期组60例，晚期组94例）。两组间损伤严重程度评分、头部简明损伤量表评分及内科合并症（充血性心力衰竭、痴呆、既往中风、慢性阻塞性肺疾病、恶性肿瘤）相似。晚期组患者更年轻（69.9岁对75.3岁，p = 0.04）。晚期组患者的LOS显著更长（17.5天对7.0天，p < 0.01），中位住院费用更高（53,165美元对17,654美元，p < 0.01）。早期组患者的呼吸机使用天数减少（2.4天对7.0天，p < 0.01），气管切开术和手术喂养管的使用率降低（1.7%对11.7%，p = 0.03）。
结论
即使在纠正晚期组会诊延迟后，早期接受PC会诊的创伤患者LOS更短，呼吸机使用天数减少，侵入性操作率降低，费用更低。这些发现表明需要建立机制，使重症创伤患者能更早接受PC会诊。
证据级别
治疗/护理管理；四级。
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