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Impact of the Emergency Department Medical Consortium Model on Patients in Intensive Care Units at Downstream Hospitals
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摘要:
目的 评估北京协和医院急诊科-北京市隆福医院“点对下游医院多科室”急诊专科医联体模式在危重症患者救治中的作用。 方法 回顾性收集2018年12月—2020年11月北京市隆福医院ICU患者的临床资料，并根据是否建立急诊专科医联体，将患者分为建立前组(2018年12月—2019年11月)和建立后组(2019年12月—2020年11月)。比较两组临床资料、疾病谱、接受检查/治疗情况及院内死亡率。 结果 共350例符合纳入与排除标准的ICU患者入选本研究。其中急诊专科医联体建立前组126例，建立后组224例(其中162例为医联体转诊患者)。建立前组患者疾病谱主要由常见的危重症疾病构成，其中占比居前3位的疾病分别为急性心血管疾病(34.1%)、重症肺炎(25.4%)、外科手术后(19.0%)，建立后组患者疾病谱多样性增加，其中占比居前3位的疾病分别为重症肺炎(31.2%)、肾功能衰竭(13.8%)、急性脑血管病(9.8%)。相较于建立前组，建立后组年龄降低[68.50(57.00, 79.00)岁比78.00 (68.25, 84.00)岁，P＜0.001]，急性生理学和慢性健康状况Ⅱ评分[18.00 (14.00, 24.00)分比15.00 (12.00, 22.75)分，P=0.005]，序贯器官衰竭估计(sequential organ failure assessment, SOFA)评分[5.00 (3.00, 7.25)分比3.00(2.00, 6.00)分，P＜0.001]，中心静脉置管(52.7%比20.6%, P＜0.001)、连续性肾脏替代治疗(22.3%比4.0%, P＜0.001)、使用血管活性药物(21.4%比11.9%, P=0.037)、去甲肾上腺素(17.0%比7.1%, P=0.015)的比例均显著升高，住院时间[(11.61±9.41) d比(10.06±7.63)d, P=0.260]、住院费用[(18 982.35 (9251.80, 51 677.59)元比39 113.11(19 500.03, 68 981.90)元, P=0.067]、院内死亡率(12.1%比10.3%, P=0.753)均无显著变化。此外，急诊专科医联体建立后，北京市隆福医院ICU收治了25例疑难病患者(急诊专科医联体建立前无疑难病患者)，并开展了多项新技术，其中实施床旁支气管镜操作9例，床旁超声检查105例。多因素Logistic回归分析结果显示，在调整年龄、SOFA评分等因素后，建立急诊专科医联体对ICU患者院内死亡率无显著影响(OR=0.994，95% CI：0.401~2.464，P=0.990)。 结论 北京协和医院急诊科-北京市隆福医院“点对下游医院多科室”急诊专科医联体建立后，在北京市隆福医院ICU患者病种复杂程度及危重程度增加的同时，患者院内死亡率无明显增加。急诊专科医联体可能有助于提升下游医院危重症患者救治能力。 Abstract:Objective To evaluate the impact of the "point to downstream hospital multi-department" emergency medical consortium model between Peking Union Medical College Hospital (PUMCH) and Beijing Longfu Hospital on the treatment of critically ill patients. Methods Clinical data of ICU patients at Beijing Longfu Hospital from December 2018 to November 2020 were retrospectively collected. The patients were categorized into two groups based on whether the emergency medical consortium was established: the pre-establishment group (December 2018 to November 2019) and the post-establishment group (December 2019 to November 2020). Clinical data, disease spectrum, examination/treatment utilization, and in-hospital mortality were compared between the two groups. Results A total of 350 ICU patients meeting the inclusion and exclusion criteria were included in this study. The pre-establishment group comprised 126 patients, while the post-establishment group had 224 patients(including 162 transferred via the consortium). In the pre-establishment group, the disease spectrum primarily consisted of common critical illnesses, with the top three diseases being acute cardiovascular diseases (34.1%), severe pneumonia (25.4%), and post-surgical cases (19.0%). In the post-establishment group, there was a greater diversity in the disease spectrum, with the top three diseases being severe pneumonia (31.2%), renal dysfunction (13.8%), and acute cerebrovascular disease (9.8%). Compared to the pre-establishment group, the post-establishment group had a lower average age [68.50(57.00, 79.00) years vs. 78.00(68.25, 84.00) years, P < 0.001], higher acute physiology and chronic health evaluation Ⅱ score [18.00(14.00, 24.00) points vs. 15.00(12.00, 22.75) points, P=0.005] and sequential organ failure assessment (SOFA) score [5.00(3.00, 7.25) points vs. 3.00(2.00, 6.00) points, P < 0.001], higher rates of central venous catheterization (52.7% vs. 20.6%, P < 0.001), continuous renal replacement therapy(22.3% vs. 4.0%, P < 0.001), vasoactive drug use (21.4% vs. 11.9%, P=0.037), and epinephrine usage (17.0% vs. 7.1%, P=0.015), and hospital stay [(11.61±9.41)days vs. (10.06±7.63)days, P=0.260], hospital costs [(18 982.35(9251.80, 51 677.59) CNY vs. 39 113.11(19 500.03, 68 981.90) CNY, P=0.067], and in-hospital mortality (12.1% vs. 10.3%, P=0.753) showed no significant changes. Furthermore, after the establishment of the emergency medical consortium, the ICU of Beijing Longfu Hospital admitted and treated 25 cases of difficult-to-treat patients (no difficult-to-treat patients were seen before the establishment of the emergency medical consortium) and used a number of new technologies, including bedside bronchoscopy in 9 cases and bedside ultrasound examination in 105 cases. Multivariable Logistic regression analysis results indicated that after adjusting for factors such as age and SOFA score, the establishment of the emergency medical consortium had no significant impact on in-hospital mortality among ICU patients (OR=0.994, 95% CI: 0.401-2.464, P=0.990). Conclusions After the establishment of the "point to downstream hospital multi-department" emergency medical consortium between PUMCH and Beijing Longfu Hospital, the complexity and severity of diseases treated in Beijing Longfu Hospital's ICU increased, but the in-hospital mortality rate did not significantly rise. The emergency medical consortium model may contribute to enhancing the capacity for treating critically ill patients in downstream hospitals. -
Key words:
- emergency medical consortium /
- referral /
- downstream hospital /
- sequential treatment
作者贡献：姜辉、韩蒙蒙负责设计实施、数据收集与分析、论文撰写；徐军负责研究设计与指导；朱华栋、刘继海、于学忠、孙佳、卢艳丽负责研究实施；史迪负责提供技术支持与指导。利益冲突：所有作者均声明不存在利益冲突 -
表 1 急诊专科医联体建立前后下游医院ICU患者主要临床资料比较
指标 建立前组(n=126) 建立后组(n=224) P值 男性[n(%)] 76(60.3) 136(60.7) ＞0.999 年龄[M(P25, P75), 岁] 78.00(68.25, 84.00) 68.50(57.00, 79.00) ＜0.001 体温[M(P25, P75), °] 36.60(36.40, 36.90) 36.70(36.50, 37.10) 0.097 心率[M(P25, P75), 次/min] 79.50(70.00, 95.75) 88.50(76.75, 102.00) 0.008 收缩压[M(P25, P75), mm Hg] 130.00(118.00, 142.00) 125.00(109.00, 147.00) 0.411 舒张压[M(P25, P75), mm Hg] 69.50(63.00, 79.00) 70.00(61.00, 82.25) 0.496 APACHE Ⅱ评分[M(P25, P75), 分] 15.00(12.00, 22.75) 18.00(14.00, 24.00) 0.005 SOFA评分[M(P25, P75), 分] 3.00(2.00, 6.00) 5.00(3.00, 7.25) ＜0.001 pH[M(P25, P75)] 7.42(7.38, 7.46) 7.45(7.41, 7.49) 0.001 PaO2[M(P25, P75), mm Hg] 85.00(67.75, 113.00) 87.50(68.75, 112.50) 0.962 PaCO2[M(P25, P75), mm Hg] 38.50(34.00, 43.00) 36.00(31.00, 42.00) 0.101 乳酸[M(P25, P75), mmol/L] 1.50(1.10, 2.50) 1.30(0.90, 1.90) 0.004 白细胞[M(P25, P75), ×109/L] 7.89(5.82, 11.50) 9.25(6.22, 12.83) 0.143 血红蛋白[M(P25, P75), g/L] 119.50(98.50, 132.70) 98.00(78.75, 120.50) ＜0.001 血小板[M(P25, P75), ×109/L] 195.00(153.75, 240.00) 170.50(111.00, 233.75) 0.003 尿素氮[M(P25, P75), mmol/L] 6.95(4.80, 12.15) 10.70(6.07, 21.70) ＜0.001 肌酐[M(P25, P75), μmol/L] 79.00(61.25, 106.00) 92.00(59.00, 218.50) 0.035 白蛋白[M(P25, P75), g/L] 35.00(29.25, 39.00) 30.00(27.00, 35.00) ＜0.001 凝血酶原时间[M(P25, P75), s] 12.10(11.30, 13.10) 12.70(11.80, 14.55) ＜0.001 D-二聚体[M(P25, P75), mg/L] 478.00(238.50, 2105.50) 899.00(480.00, 2415.00) ＜0.001 APACHE Ⅱ：急性生理学和慢性健康状况Ⅱ；SOFA：序贯器官衰竭估计；PaO2：动脉血氧分压；PaCO2：动脉血二氧化碳分压 
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表 2 下游医院ICU患者院内死亡危险因素的多因素Logistic回归分析
指标 β值 SE Wald值 OR值(95% CI) P值 年龄 0.071 0.019 14.408 1.074(1.035~1.114) 0.000 SOFA评分 0.240 0.059 16.835 1.272(1.134~1.426) 0.000 血红蛋白 0.000 0.008 0.001 1.000(0.984~1.016) 0.973 白蛋白 0.013 0.017 0.609 1.013(0.980~1.048) 0.435 尿素氮 -0.061 0.040 2.256 0.941(0.870~1.019) 0.133 凝血酶原时间 -0.003 0.018 0.025 0.997(0.963~1.033) 0.875 D-二聚体 0.000 0.000 6.247 1.000(1.000~1.000) 0.012 CRRT -0.947 0.545 3.015 0.388(0.133~1.130) 0.082 建立急诊专科医联体 -0.006 0.463 0.000 0.994(0.401~2.464) 0.990 SOFA：同表 1；CRRT：连续性肾脏替代治疗
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