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[JAMA Intern Med在线发表]:危重病患者从ICU直接出院回家是否安全?
2018年09月28日 时讯速递, 进展交流 暂无评论

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study.

Stelfox HT, Soo A, Niven DJ, et al

JAMA Intern Med. 2018 Aug 20. doi: 10.1001/jamainternmed.2018.3675. [Epub ahead of print]

IMPORTANCE: 背景

The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.

病情恢复的危重病成年患者从ICU直接出院回家的安全性尚不清楚。

OBJECTIVE: 目的

To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward.

比较从ICU直接出院患者与从普通病房出院的ICU患者医疗资源利用及临床预后。

DESIGN, SETTING, AND PARTICIPANTS: 设计,场景及研究人群

Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics.

2014年1月1日至2016年1月1日间,在9个医院的ICU进行的基于人口的回顾性队列研究,出院后随访1年。所有存活出院的成年ICU患者均入选,根据患者特征、在ICU接受的治疗以及医院特征建立倾向性评分,并根据倾向性评分建立匹配(1:1)队列。

EXPOSURES: 暴露因素

Patient disposition on discharge from the ICU: directly home vs home via the hospital ward.

患者从ICU转出的去向:直接回家 vs. 经普通病房出院回家

MAIN OUTCOMES AND MEASURES: 主要预后指标

The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year.

主要预后指标为出院30天内再次入院。次要预后指标为出院30天内急诊就诊,以及1年内死亡。

RESULTS: 结果

Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35).

在研究入选的 6732 名患者中,2826名 (42%) 为女性,中位年龄 56 岁(四分位区间,41-67 岁);922名 (14%) 患者直接出院回家,各医院之间存在明显差异(范围,4.4%-44.0%)。与经普通病房出院回家的患者相比,直接出院回家的患者年龄较轻(中位年龄 47 vs 57 岁;P < .001),因药物过量、戒断、癫痫或代谢性昏迷入院比例更高 (32% [295] vs 10% [594]; P < .001),且入ICU时病情较轻(中位APACHE II评分 15 vs 18; P < .001),有创机械通气时间不足48小时比例更高 (42% [389] vs 34% [1984]; P < .001)。对于倾向性评分匹配队列 (n = 1632),与经普通病房出院回家的患者相比,直接出院回家的患者ICU住院日相似(中位数3.1 天 vs 3.0 天; P = .42),但总住院日较短(中位数3.3 天 vs 9.2 天; P < .001)。两组患者出院后30天内再次入院(10% [n = 81] vs 11% [n = 92]; 风险比 [HR], 0.88; 95% CI, 0.64-1.20) 或急诊就诊(25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09)的比例无显著差异。两组患者分别有4%在出院1年内死亡(直接出院回家患者及经普通病房出院回家患者分别有31和34例)(HR, 0.90; 95% CI, 0.60-1.35)。

CONCLUSIONS AND RELEVANCE: 结论与意义

The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.

某些成年ICU患者从ICU直接出院回家的情况比较普遍,且并不伴随医疗资源使用或病死率增加。

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