高科技監測與重症病患得到更佳的結果有關

作者：Norra MacReady  
出處：WebMD醫學新聞

　　April 13, 2010 — 一項登載於4月12日內科醫學誌(Archives of Internal Medicine)線上版的研究指出，使用資訊科技與遙控醫師監測的全天候觀察方式，與死亡率降低有關。
　　
　　研究結論指出，這是首次有研究發現提出，綜合性整合健康資訊科技運用，加上遙控專責主治醫師照護(remote intensivist coverage，RIC)，可以對無法提供全年無休專責主治醫師的加護病房(ICU)有所幫助。
　　
　　在10個月間，以一個大學附設社區醫院的3個ICU、共36床監測病床的病患為研究對象，每個病房皆建置一個同等的健康資訊科技束(HITB)-RIC系統，包括電子病歷、醫令輸入、給藥系統、以及可讓沒在現場的專責主治醫師使用的視聽監控設備。
　　
　　第一作者、賓州州立醫學院重症照護小組Matthew McCambridge醫師等人寫道，從晚上7點到早上7點，遠距醫療團隊都可以收住新病患，回答ICU護士有關病患問題的來電，回應監測電腦發出的訊息，檢視電子病歷的演算事件系統，其他重要改變包括，RIC團隊可以回應處置病患的：
　　* 血壓
　　* 心律
　　* 檢驗值
　　* 機械輔助呼吸參數，以及
　　* 中樞神經和肺動脈導管值等等的變化。
　　
　　作者們解釋，比較資料獲自建置HITB-RIC系統之前16個月、同樣3個ICU的住院病患。
　　
　　HITB-RIC組共蒐集了959名病患、控制組有954名病患的資料，除了比較粗死亡率之外，研究者根據每個病患的「急性生理和慢性健康評估系統第四版(APACHE)-IV)」分數和「APACHE 急性生理分數(APACHE-APS)」，比較了預測死亡率，他們也探討了機械輔助呼吸之需求和住院天數。
　　
　　觀察發現，HITB-RIC組住院死亡率為14.7%，控制組為21.4% (P < .001)，相較於預測死亡率， HITB-RIC組根據APACHE-IV的預測死亡率為75.8%，控制組的APACHE-IV預測死亡率則超過100% (P < .001)。當根據APACHE-IV預測的急性觀察住院死亡率，依照各診斷類別區分病患時，神經、心血管、胃腸道、呼吸道疾病患者的標準死亡率比率減少至少19%。神經和胃腸道疾病HITB-RIC組病患的觀察死亡率顯著低於控制組(P值分別是P = .002 和 P = .04)。
　　
　　同樣地，HITB-RIC組有31.5%的病患需要呼吸器，控制組為36.1%(P = .001)，兩組的ICU住院天數或總住院天數之間並無顯著差異。
　　
　　研究限制包括，屬於觀察型研究且只有在一個醫院進行，因此，這個研究發現無法一般化，此外，這些研究發現會受到收集的資料差異而影響，控制組的是紙本資料，HITB-RIC組的是電子化資料，不過，作者們寫道，研究資料認為，HITB-RIC模式代表重症照護醫療品質的重大進步，在合格專責主治醫師缺乏之下，仍可以改善病患接受重症照護的程度。
　　
　　作者們皆宣告沒有相關財務關係。


High-Tech Monitoring Associated With Better Outcomes in Critically Ill Patients

By Norra MacReady
Medscape Medical News

April 13, 2010 — Round-the-clock observation using a combination of information technology and remote physician monitoring is associated with lower-than-predicted mortality, investigators reported in a study published online April 12 in the Archives of Internal Medicine.

As described in the study conclusion, these findings may be the first to demonstrate the advantages of a comprehensive and integrated health information technology application combined with remote intensivist coverage (RIC) over a standard, intensive-care unit (ICU) model that does not provide 24/7 intensivist coverage.

For 10 months, the researchers studied patients admitted consecutively to 3 ICUs with a total of 36 monitored beds in a single academic community hospital. A coordinated health information technology bundle (HITB)-RIC system was installed in each unit, consisting of electronic medical records, order entry, and medication administration systems, as well as audiovisual equipment that permitted monitoring by off-site intensivists.

"From 7 PM to 7 AM, the telemedicine team admitted new patients, responded to telephone calls from ICU nurses about their patients, and responded to computer-generated events, as identified by the electronic medical record's algorithmic event system," write lead author Matthew McCambridge, MD, from the Division of Critical Care Medicine, Pennsylvania State College of Medicine, Hershey, and colleagues. Among other critical changes, the RIC team responded to variations in patients'

blood pressure,
heart rate,
laboratory values,
mechanical ventilator parameters, and
central venous and pulmonary artery catheter values.
Comparison data were obtained from patients admitted consecutively to the same 3 ICUs during the 16 months preceding the implementation of the HITB-RIC, explain the authors.

They collected information on 959 patients in the HITB-RIC group and 954 patients in the control group. In addition to comparing crude mortality rates, the investigators compared predicted mortality based on each patient's score on the Acute Physiology and Chronic Health Evaluation (APACHE)-IV and APACHE Acute Physiology Score (APACHE-APS). They also looked at need for mechanical ventilation and hospital length of stay.

Observed hospital mortality was 14.7% in the HITB-RIC group and 21.4% in the control group (P < .001). Compared with predicted mortality, the rate among patients in the HITB-RIC group was 75.8% of that predicted by APACHE-IV (P < .001) and more than 100% of the predicted APACHE-IV mortality rate for the control group. When the patients were divided into diagnostic categories, the standardized mortality ratio, obtained by dividing the actual observed hospital mortality by that predicted by APACHE-IV, was reduced by at least 19% among patients with neurologic, cardiovascular, gastrointestinal, and respiratory illnesses. HITB-RIC patients with neurologic and gastrointestinal illnesses had significantly lower observed mortality rates compared with the control group (P = .002 and P = .04, respectively).

Similarly, 31.5% of the patients in the HITB-RIC group required ventilators compared with 36.1% of those in the control group (P = .001). There were no significant differences between the groups in ICU length of stay or overall hospital length of stay.

Limitations of the study include that it was observational and conducted at a single hospital; therefore, the findings may not be generalizable. In addition, the findings may have been affected by differences in data collection, which was paper-based for the control group and electronic for the HITB-RIC group. Nevertheless, the authors write, the data suggest that the HITB-RIC model "represents a significant advancement in the quality of critical care medicine" and could improve patient access to good critical care despite a growing shortage of qualified intensivists.

The authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:648-653.