高风险病房患者临床病情恶化事件的相关原因、诊断测试和治疗。

Matthew M Churpek, Ryan Ingebritsen, Kyle A Carey, Saieesh A Rao, Emily Murnin, Tonela Qyli, Madeline K Oguss, Jamila Picart, Leena Penumalee, Benjamin D Follman, Lily K Nezirova, Sean T Tully, Charis Benjamin, Christopher Nye, Emily R Gilbert, Nirav S Shah, Christopher J Winslow, Majid Afshar, Dana P Edelson
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引用次数: 0

摘要

重要性:要对临床病情恶化的病房病人进行及时干预,护理团队就必须准确诊断和治疗他们的潜在病症。然而,导致病情恶化的最常见诊断和提供的相关治疗方法却鲜为人知:我们旨在通过人工病历审查确定导致高危病房患者临床病情恶化的诊断、下达的相关诊断检测指令以及采取的治疗方法:这是一项多中心回顾性观察研究,从 2006 年至 2020 年在四个医疗系统的内外科住院病房进行。研究对象包括随机抽取的临床病情恶化的患者(每个医疗系统各1000名),病情恶化的定义是达到有效预警评分--电子心脏骤停风险分级的第95百分位数:临床病情恶化由经过培训的审查员确认,如果每位患者的病情没有恶化,则标记为误报。对于真正的病情恶化事件,则收集导致病情恶化的病症、开具的相关诊断检查单和提供的治疗:结果:在纳入的 4000 名患者中,有 2484 人(62%)通过病历审查确认了临床病情恶化。败血症是最常见的病情恶化原因(41%;n = 1021),其次是心律失常(19%;n = 473),而肝功能衰竭的院内死亡率最高(41%)。最常见的诊断检查是全血细胞计数(47%),其次是胸片(42%)和培养(40%),而最常见的药物是抗菌药物(46%),其次是液体注射(34%)和抗心律失常药物(19%):我们发现败血症是最常见的病情恶化原因,而肝功能衰竭的死亡率最高。全血细胞计数和胸片是最常见的诊断检查项目,抗菌药和补液是最常见的药物干预措施。这些结果为床边的临床决策、快速反应团队的培训以及临床恶化的机构治疗路径的制定提供了重要的启示。
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Causes, Diagnostic Testing, and Treatments Related to Clinical Deterioration Events Among High-Risk Ward Patients.

Importance: Timely intervention for clinically deteriorating ward patients requires that care teams accurately diagnose and treat their underlying medical conditions. However, the most common diagnoses leading to deterioration and the relevant therapies provided are poorly characterized.

Objectives: We aimed to determine the diagnoses responsible for clinical deterioration, the relevant diagnostic tests ordered, and the treatments administered among high-risk ward patients using manual chart review.

Design, setting, and participants: This was a multicenter retrospective observational study in inpatient medical-surgical wards at four health systems from 2006 to 2020. Randomly selected patients (1000 from each health system) with clinical deterioration, defined by reaching the 95th percentile of a validated early warning score, electronic Cardiac Arrest Risk Triage, were included.

Main outcomes and measures: Clinical deterioration was confirmed by a trained reviewer or marked as a false alarm if no deterioration occurred for each patient. For true deterioration events, the condition causing deterioration, relevant diagnostic tests ordered, and treatments provided were collected.

Results: Of the 4000 included patients, 2484 (62%) had clinical deterioration confirmed by chart review. Sepsis was the most common cause of deterioration (41%; n = 1021), followed by arrhythmia (19%; n = 473), while liver failure had the highest in-hospital mortality (41%). The most common diagnostic tests ordered were complete blood counts (47% of events), followed by chest radiographs (42%) and cultures (40%), while the most common medication orders were antimicrobials (46%), followed by fluid boluses (34%) and antiarrhythmics (19%).

Conclusions and relevance: We found that sepsis was the most common cause of deterioration, while liver failure had the highest mortality. Complete blood counts and chest radiographs were the most common diagnostic tests ordered, and antimicrobials and fluid boluses were the most common medication interventions. These results provide important insights for clinical decision-making at the bedside, training of rapid response teams, and the development of institutional treatment pathways for clinical deterioration.

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