急诊普通外科的规范化护理路径：系统评价和荟萃分析。
Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis.
机构信息
Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK.
Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
出版信息
Br J Surg. 2024 Mar 2;111(3). doi: 10.1093/bjs/znae057.
BACKGROUND
Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes.
METHODS
The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling.
RESULTS
Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001).
DISCUSSION
Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.
背景
急诊腹部手术与显著的术后发病率和死亡率相关。在这种情况下提供标准化途径可能具有改变临床护理并改善患者结局的潜力。
方法
在 1950 年 1 月至 2022 年 10 月期间，检索了 OVID SP 版本的 MEDLINE、EMBASE 和 Cochrane 对照试验中心注册库。纳入了比较成年患者（>18 岁）接受主要急诊腹部手术后 30 天随访数据的协议化护理流程与标准护理方案的随机和非随机队列研究。如果研究报告的是创伤或择期环境中的标准化护理方案，则将其排除在外。评估的结局包括住院时间、30 天术后发病率、30 天术后死亡率以及 30 天再入院和再手术率。使用 ROBINS-I 评估非随机研究的偏倚风险，使用 RoB-2 评估随机对照试验的偏倚风险。使用随机效应模型进行荟萃分析。
结果
确定了 17 项研究，共纳入 20927 例患者，其中 12359 例患者接受了协议化护理路径，8568 例患者接受了标准护理路径。确定了 13 种独特的协议化途径，每条途径的中位数有 8 个组成部分（范围为 6-15），依从率为 24-100%。与标准护理路径相比，协议化护理路径与较短的住院时间相关（平均差异-2.47，95%置信区间-4.01 至-0.93，P=0.002）。协议化护理路径对术后死亡率没有影响（OR 0.87，95%置信区间 0.41 至 1.87，P=0.72）。观察到特定术后并发症的发生率降低，包括术后肺炎（OR 0.42，95%置信区间 0.24 至 0.73，P=0.002）和手术部位感染（OR 0.34，95%置信区间 0.21 至 0.55，P<0.001）。
讨论
目前，急诊环境中的协议化护理路径缺乏标准化，具有不同的组成部分和低依从性；然而，尽管如此，它们与短期临床获益相关。
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