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[JAMA在线发表]:采用儿科早期预警系统不能降低住院患儿的全因病死率
2018年03月21日 时讯速递, 进展交流 暂无评论

Original Investigation

Caring for the Critically Ill Patient

February 27, 2018

Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial

Christopher S. Parshuram, Karen Dryden-Palmer, Catherine Farrell, et al

JAMA. Published online February 27, 2018. doi:10.1001/jama.2018.0948

Abstract

Importance 背景

There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes.

有限证据表明,儿科患者采用疾病严重程度评分有利于及时收入ICU或改善预后。

Objective 目的

To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use.

确定床旁儿科早期预警系统(BedsidePEWS)对全因住院病死率、后期收入ICU、心跳骤停及ICU资源使用的影响。

Design, Setting, and Participants 设计、场景和研究人群

A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015.

7个国家(比利时,加拿大,英格兰,爱尔兰,意大利,新西兰与荷兰)负责婴儿(孕周 ≥37 周)到儿童(年龄 ≤18 岁)住院诊疗的21家医院参加的多中心群组随机试验。参研中心有医师提供不间断服务,并有儿科亚专科服务。2011年2约28日开始入选患者,2015年6月21日终止入选。2015年7月19日随访截止。

Interventions 干预措施

The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals).

BedsidePEWS干预组(10所医院)与常规治疗(无疾病严重程度评分;11所医院)进行比较

Main Outcomes and Measures 主要预后指标

The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates.

主要预后指标为全因住院病死率。次要预后指标为临床恶化事件,定义为反映后期收入ICU的复合预后指标。针对医院水平群组及基线水平进行回归分析。

Results 结果

Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, −0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, −0.34 [95% CI, −0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03).

21所医院共有144539名患儿出院,共有559443住院日及144539名(100%)患儿完成试验。BedsidePEWS医院组全因住院病死率为1.93/1000出院患儿,常规治疗医院组为1.56/1000出院患儿(校正后组间差异0.01 [95% CI, −0.80 to 0.81 /1000出院患儿];校正后比数比,1.01 [95% CI, 0.61 to 1.69]; P = .96)。BedsidePEWS医院组临床恶化事件发生率为0.5/1000住院日,常规治疗组为0.84/1000住院日(校正后组间差异−0.34 [95% CI, −0.73 to 0.05/1000住院日];校正后比数比,0.77 [95% CI, 0.61 to 0.97]; P = .03)。

Conclusions and Relevance 结论与意义

Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality.

与常规治疗相比,采用床旁儿科早期预警系统不能显著降低住院患儿的全因病死率。这些结果不支持使用这一评分降低病死率。

Trial Registration 试验注册

clinicaltrials.gov Identifier: NCT01260831

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