2014年11月27日文献精读之一

Am J Respir Crit Care Med. 2014 Nov 4. [Epub ahead of print]
The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative.

Rationale: The Centers for Disease Control and Prevention (CDC) introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs.

Objectives: To assess the preventability of VAEs.

Methods: We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance amongst 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining 8 units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, SOFA score, and comorbidity index.

Measurements and Main Results: We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator-day but significant decreases in VAE risk per episode of mechanical ventilation (OR 0.63, 95% CI 0.42-0.97) and infection-related ventilator-associated complications (OR 0.35, 95% CI 0.17-0.71) but not pneumonias (OR 0.51, 95% CI 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates.

Conclusions: Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01583413.
PMID: 25369558

Intensive Care Med. 2014 Nov;40(11):1688-97. doi: 10.1007/s00134-014-3425-2. Epub 2014 Aug 13.
Quality of dying in the ICU: is it worse for patients admitted from the hospital ward compared to those admitted from the emergency department?
Long AC1, Kross EK, Engelberg RA, Downey L, Nielsen EL, Back AL, Curtis JR.

OBJECTIVE:
Although most intensive care unit (ICU) admissions originate in the emergency department (ED), a substantial number of admissions arrive from hospital wards. Patients transferred from the hospital ward often share clinical characteristics with those admitted from the ED, but family expectations may differ. An understanding of the impact of ICU admission source on family perceptions of end-of-life care may help improve patient and family outcomes by identifying those at risk for poor outcomes.
DESIGN AND SETTING:
This was a cohort study of patients with chronic illness and acute respiratory failure requiring mechanical ventilation who died after admission to an ICU in any of the 14 participating hospitals in the Seattle-Tacoma area between 2003 and 2008 (n = 1,500).
MEASUREMENTS:
Using regression models adjusted for hospital site and patient-, nurse- and family-level characteristics, we examined associations between ICU admission source (hospital ward vs. ED) and (1) family ratings of satisfaction with ICU care; (2) family and nurse ratings of quality of dying; (3) chart-based indicators of palliative care.
MAIN RESULTS:
Admission from the hospital ward was associated with lower family ratings of quality of dying [β -0.90, 95 % confidence interval (CI) -1.54, -0.26, p = 0.006] and satisfaction (total score β -3.97, 95 % CI -7.89, -0.05, p = 0.047; satisfaction with care domain score β -5.40, 95 % CI -9.44, -1.36, p = 0.009). Nurses did not report differences in quality of dying. Patients from hospital wards were less likely to have family conferences [odds ratio (OR) 0.68, 95 % CI 0.52, 0.88, p = 0.004] or discussion of prognosis in the first 72 h after ICU admission (OR 0.72, 95 % CI 0.56, 0.91, p = 0.007) but were more likely to receive spiritual care (OR 1.48, 95 % CI 1.14, 1.93, p = 0.003) or have life support withdrawn (OR 1.38, 95 % CI 1.04, 1.82, p = 0.025).
CONCLUSION:
Admission from the hospital ward is associated with family perceptions of a lower quality of dying and less satisfaction with ICU care. Differences in receipt of palliative care suggest that family of patients from the hospital ward receive less communication. Nurse ratings of quality of dying did not significantly differ by ICU admission source, suggesting dissimilarities between family and nurse perspectives. This study identifies a patient population at risk for poor quality palliative and end-of-life care. Future studies are needed to identify interventions to improve care for patients who deteriorate on the wards following hospital admission.
PMID: 25116294