Hanson L C, Danis M, Lazorick S
Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill 27599-7110.
J Am Geriatr Soc. 1994 Dec;42(12):1277-81. doi: 10.1111/j.1532-5415.1994.tb06511.x.
To identify predictors of 6-month mortality known before emergent admission to intensive care (IC) and to describe obstacles to the use of patient preferences in emergency triage decisions.
Historical cohort.
A 600-bed university hospital.
263 consecutive patients triaged in the emergency room to receive intensive care.
Medical records were abstracted for age, performance status, and chronic disease severity as predictors of 6-month survival. Acute Physiology Score (APS) in the emergency room was used as a measure of acute illness severity. Deaths during the 6 months following IC admission were determined from record review and death certificate data. Obstacles to communication of patient treatment preferences at the time of triage were described. Six-month mortality was 19 percent, and increased with increasing APS, age > or = 80 (43%), poor performance status (56%), and severe chronic disease (33%) (P < or = 0.01). In multivariate analysis, APS, age > or = 80 and performance status were independent predictors of 6-month mortality. Only APS predicted mortality in hospital. The most common obstacles to use of patient preferences in triage decisions were absence of documented advance directives (95%) and the brief duration of acute illness (72%). Mental status changes were very common in the emergency room for nonsurvivors (61%), but chronic cognitive impairment was rare (3%).
Patients with poor performance status or very advanced age have increased mortality within 6 months of emergent triage to IC. Mental status changes, absence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences before the time of emergent decisions about IC.
确定重症监护病房（IC）紧急入院前已知的6个月死亡率预测因素，并描述在急诊分诊决策中使用患者偏好的障碍。
历史性队列研究。
一家拥有600张床位的大学医院。
263例在急诊室接受分诊以接受重症监护的连续患者。
提取病历中的年龄、功能状态和慢性病严重程度作为6个月生存率的预测因素。急诊室的急性生理评分（APS）用作急性疾病严重程度的衡量指标。通过病历审查和死亡证明数据确定IC入院后6个月内的死亡情况。描述了分诊时患者治疗偏好沟通的障碍。6个月死亡率为19%，并随APS升高、年龄≥80岁（43%）、功能状态差（56%）和严重慢性病（33%）而增加（P≤0.01）。多变量分析中，APS、年龄≥80岁和功能状态是6个月死亡率的独立预测因素。仅APS可预测院内死亡率。分诊决策中使用患者偏好的最常见障碍是缺乏记录的预先指示（95%）和急性疾病持续时间短（72%）。非幸存者在急诊室的精神状态改变非常常见（61%），但慢性认知障碍很少见（3%）。
功能状态差或年龄非常大的患者在紧急分诊至IC后6个月内死亡率增加。精神状态改变、缺乏预先指示和时间限制是分诊时患者偏好沟通的常见障碍。初级保健医生需要在做出关于IC的紧急决策之前引出并记录患者的偏好。
