Rosenthal G E, Sirio C A, Shepardson L B, Harper D L, Rotondi A J, Cooper G S
Cleveland Veterans Affairs Medical Center and University Hospitals of Cleveland, the Department of Medicine, Case Western Reserve University School of Medicine, Ohio 44106-4961, USA.
Arch Intern Med. 1998 May 25;158(10):1144-51. doi: 10.1001/archinte.158.10.1144.
To determine variations among hospitals in use of intensive care units (ICUs) for patients with low severity of illness.
Retrospective cohort study.
Twenty-eight hospitals with 44 ICUs in a large metropolitan region.
Consecutive eligible patients (N=104,487) admitted to medical, surgical, neurological, or mixed medical-surgical ICUs from March 1, 1991, to March 31, 1995.
The predicted risk of in-hospital death for each patient was assessed using a validated method that is based on age, ICU admission source, diagnosis, severe comorbid conditions, and abnormalities in 17 physiologic variables. Admissions were classified as low severity if the patient's predicted risk of death was less than 1%. In a subset of 12,929 consecutive patients, use of 19 specific interventions typically delivered in ICUs was examined.
Twenty thousand four hundred fifty-one admissions (19.6%) were categorized as low severity, including 23.6% of postoperative and 16.9% of nonoperative admissions. Alcohol and other drug overdoses accounted for 40.2% of nonoperative low-severity admissions; laminectomy and carotid endarterectomy accounted for 52.3% of postoperative low-severity admissions. Mortality among patients with low-severity illness was 0.3%, and only 28.6% received an ICU-specific intervention during the first ICU day. Although mean ICU length of stay was shorter (P<.001) in low-severity admissions (2.2 vs 4.7 days in nonoperative and 2.4 vs 4.2 days in postoperative admissions), low-severity admissions accounted for 11.1% of total ICU bed days. Rates of low-severity admissions varied (P<.001) across hospitals, ranging from 5% to 27% for nonoperative and 9% to 68% for postoperative admissions.
A large proportion of patients admitted to the ICU have a low probability of death and do not receive ICU-specific interventions. Rates of low-severity admissions varied among hospitals. The development and implementation of protocols to target ICU care to patients most likely to benefit may decrease the number of low-severity ICU admissions and improve the cost-effectiveness of ICU care.
确定各医院对病情较轻患者使用重症监护病房（ICU）的差异。
回顾性队列研究。
大都市地区的28家医院，共44个ICU。
1991年3月1日至1995年3月31日期间连续入住内科、外科、神经科或内科-外科混合ICU的符合条件患者（N = 104,487）。
采用一种经过验证的方法评估每位患者院内死亡的预测风险，该方法基于年龄、ICU入院来源、诊断、严重合并症以及17项生理变量的异常情况。如果患者的死亡预测风险低于1%，则将入院分类为低病情严重程度。在12,929例连续患者的子集中，研究了ICU中通常实施的19种特定干预措施的使用情况。
20451例入院患者（19.6%）被分类为低病情严重程度，包括23.6%的术后患者和16.9%的非手术患者。酒精和其他药物过量占非手术低病情严重程度入院患者的40.2%；椎板切除术和颈动脉内膜切除术占术后低病情严重程度入院患者的52.3%。低病情严重程度患者的死亡率为0.3%，在ICU的第一天只有28.6%的患者接受了ICU特定干预。尽管低病情严重程度入院患者的平均ICU住院时间较短（P <.001）（非手术患者为2.2天对4.7天，术后患者为2.4天对4.2天），但低病情严重程度入院患者占ICU总床日数的11.1%。各医院低病情严重程度入院率不同（P <.001），非手术患者的入院率为5%至27%，术后患者的入院率为9%至68%。
入住ICU的患者中很大一部分死亡概率较低，且未接受ICU特定干预。各医院低病情严重程度入院率不同。制定并实施针对最可能受益患者的ICU护理方案，可能会减少低病情严重程度的ICU入院人数，并提高ICU护理的成本效益。
