Gemke R J, Bonsel G J, van Vught A J
Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, Utrecht, The Netherlands.
Crit Care Med. 1994 Sep;22(9):1477-84. doi: 10.1097/00003246-199409000-00020.
To assess the performance of pediatric intensive care by an international standard.
Prospective, cohort study.
Nine-bed multidisciplinary pediatric intensive care unit (ICU) within a 174-bed, tertiary care children's hospital.
Consecutive, unselected patients (n = 612) during a 16-month period.
None.
Collected data included age, major diagnostic category, primary clinical specialty, severity of illness (daily Pediatric Risk of Mortality [PRISM] score), administration of ICU-dependent therapy (daily), and vital status at discharge. The PRISM score allowed the calculation of overall and daily mortality risk. After testing the applicability of the predictive model, effectiveness was determined by comparing severity of illness-based predicted mortality rate with vital status at discharge. Efficiency was defined by two criteria: a) the administration of at least one ICU-dependent therapy; or b) a mortality risk of > 1%. Five-hundred ninety-three patients were included (19 survivors were excluded because of incomplete data). Mean age was 55.0 months (median 24). Mean length of stay was 4.4 days (median 2). Overall ICU mortality rate was 8.4%. The overall performance of the PRISM score-based predictive model was found to be good (goodness-of-fit test chi 2[5] = 5.49; p = .35; area under receiver operating characteristic curve 0.92). Subgroup analysis showed that the best model performance was in nonoperative patients. Decreased performance was found in operative patients. In cardiovascular patients, the mortality rate was higher. In other surgical patients, the mortality rate was lower than expected. Of 593 patients, 489 (82.5%) admissions were efficient, as were 2,393 (76.5%) of 3,130 patient days in the ICU. The ranking of daily efficiency according to clinical specialty was as follows: postoperative cardiovascular surgical patients (86.3%); nonsurgical patients (76.6%); and other postoperative patients (49.6%).
In our setting, effectiveness and efficiency of pediatric intensive care appeared to be validly determined using explicit criteria (mortality risk, administration of ICU-dependent therapy). Overall effectiveness met the standard set forth in an American study; validity in stratified analysis of diagnostic subgroups remains to be further established. Efficiency showed marked, specialty-related differences. The low efficiency in other (noncardiovascular) surgical patients was probably caused by the recovery function of the ICU. A more general application of these criteria might be considered in modifying admission and discharge policy, as well as in quality control.
依据国际标准评估儿科重症监护的绩效。
前瞻性队列研究。
一家拥有174张床位的三级儿童医院内的九床位多学科儿科重症监护病房（ICU）。
16个月期间连续入选的非选择性患者（n = 612）。
无。
收集的数据包括年龄、主要诊断类别、主要临床专科、疾病严重程度（每日儿科死亡风险[PRISM]评分）、依赖ICU治疗的使用情况（每日）以及出院时的生命状态。PRISM评分可用于计算总体和每日死亡风险。在测试预测模型的适用性后，通过比较基于疾病严重程度预测的死亡率与出院时的生命状态来确定有效性。效率由两个标准定义：a）至少使用一种依赖ICU的治疗；或b）死亡风险>1%。纳入593例患者（19例幸存者因数据不完整被排除）。平均年龄为55.0个月（中位数24个月）。平均住院时间为4.4天（中位数2天）。ICU总体死亡率为8.4%。基于PRISM评分的预测模型的总体表现良好（拟合优度检验卡方[5]=5.49；p = 0.35；受试者工作特征曲线下面积0.92）。亚组分析表明，最佳模型表现见于非手术患者。手术患者的表现有所下降。心血管疾病患者的死亡率较高。其他手术患者的死亡率低于预期。在593例患者中，489例（82.5%）的入院是有效的，在ICU的3130个患者日中，2393例（76.5%）是有效的。根据临床专科划分的每日效率排名如下：术后心血管外科患者（86.3%）；非手术患者（76.6%）；以及其他术后患者（49.6%）。
在我们的研究环境中，似乎可以使用明确的标准（死亡风险、依赖ICU治疗的使用情况）有效地确定儿科重症监护的有效性和效率。总体有效性符合美国一项研究设定的标准；诊断亚组分层分析中的有效性仍有待进一步确立。效率显示出明显的、与专科相关的差异。其他（非心血管）手术患者的低效率可能是由ICU的恢复功能导致的。在修改入院和出院政策以及质量控制方面，可以考虑更广泛地应用这些标准。
