[JAMA Intern Med发表论文]：内科病房重症事件的时间聚类

Original Investigation 

July 10, 2023

Temporal Clustering of Critical Illness Events on Medical Wards

Samik Doshi, Saeha Shin, Lauren Lapointe-Shaw, et al

JAMA Intern Med. Published online July 10, 2023. doi:10.1001/jamainternmed.2023.2629

Key Points

Question  Is a critical illness event (death or intensive care unit transfer) associated with an increase in the near-term risk of critical illness in other patients on the same medical ward?

Findings  In this cohort study of 118 529 hospital admissions at 5 hospitals, patients were more likely to die or be transferred to an intensive care unit within 12 hours after another patient experienced a critical illness event on the same ward.

Meaning  Findings suggest that critical illness events tend to cluster on medical wards, and efforts to better understand this association represent important opportunities to improve patient safety.

Abstract

Importance  Recognizing and preventing patient deterioration is important for hospital safety.

Objective  To investigate whether critical illness events (in-hospital death or intensive care unit [ICU] transfer) are associated with greater risk of subsequent critical illness events for other patients on the same medical ward.

Design, Setting, and Participants  Retrospective cohort study in 5 hospitals in Toronto, Canada, including 118 529 hospitalizations. Patients were admitted to general internal medicine wards between April 1, 2010, and October 31, 2017. Data were analyzed between January 1, 2020, and April 10, 2023.

Exposures  Critical illness events (in-hospital death or ICU transfer).

Main Outcomes and Measures  The primary outcome was the composite of in-hospital death or ICU transfer. The association between critical illness events on the same ward across 6-hour intervals was studied using discrete-time survival analysis, adjusting for patient and situational factors. The association between critical illness events on different comparable wards in the same hospital was measured as a negative control.

Results  The cohort included 118 529 hospitalizations (median age, 72 years [IQR, 56-83 years]; 50.7% male). Death or ICU transfer occurred in 8785 hospitalizations (7.4%). Patients were more likely to experience the primary outcome after exposure to 1 prior event (adjusted odds ratio [AOR], 1.39; 95% CI, 1.30-1.48) and more than 1 prior event (AOR, 1.49; 95% CI, 1.33-1.68) in the prior 6-hour interval compared with no exposure. The exposure was associated with increased odds of subsequent ICU transfer (1 event: AOR, 1.67; 95% CI, 1.54-1.81; >1 event: AOR, 2.05; 95% CI, 1.79-2.36) but not death alone (1 event: AOR, 1.08; 95% CI, 0.97-1.19; >1 event: AOR, 0.88; 95% CI, 0.71-1.09). There was no significant association between critical illness events on different wards within the same hospital.

Conclusions and Relevance  Findings of this cohort study suggest that patients are more likely to be transferred to the ICU in the hours after another patient’s critical illness event on the same ward. This phenomenon could have several explanations, including increased recognition of critical illness and preemptive ICU transfers, resource diversion to the first event, or fluctuations in ward or ICU capacity. Patient safety may be improved by better understanding the clustering of ICU transfers on medical wards.