参与练习变异性在俯卧位起始中的作用

CHEST critical care Pub Date : 2025-04-08 DOI:10.1016/j.chstcc.2025.100158

Anna K. Barker MD, PhD , Emily A. Harlan MD , Meeta Prasad Kerlin MD, MSCE , Thomas S. Valley MD , Michael W. Sjoding MD

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引用次数: 0

摘要

背景：俯卧位虽然有降低死亡率的好处，但没有得到充分利用。先前的研究强调，患者独立因素可能会影响俯卧位率，但主治医生的具体贡献尚不清楚。研究问题主治医师的俯卧位率是否存在显著差异？研究设计和方法：这是一项回顾性队列研究，从2015年1月1日至2024年6月30日，514名在三级护理内科或外科ICU接受机械通气的成年人。纳入标准为插管0 ~ 36小时和36 ~ 72小时内Pao2 / Fio2比≤150，Fio2≥60%，呼气末正压≥5 cm H2O。主要结局为插管72小时内或符合俯卧位标准的24小时内俯卧位。我们假设参加变异是俯卧位的重要预测因子。我们拟合了一个混合效应logistic回归模型来评估就诊水平上俯卧位使用的可变性，调整了6个以患者为中心的潜在俯卧位障碍和促进因素（年龄、BMI、COVID-19状态、代码状态、Pao2 / Fio2比率和血管加压药物的使用）和ICU位置（内科或外科）。结果514例符合俯卧位的患者中，87例（17%）采用了俯卧位。在纳入分析的48名主治医生中，俯卧位的显着水平差异被注意到，风险和可靠性调整率从14.9%到74.2%不等，主治医生的中位OR为2.6 （95% CI, 1.7-5.2）。与Pao2 / Fio2比值降低30 mm Hg相比，俯卧位与该效应值的相关性更强。即使在获得俯卧位资格当天有ARDS临床记录的患者中，主治医生的中位OR为2.4 （95% CI, 1.5-7.3）。预测俯卧位的其他患者因素包括COVID-19状态、代码状态和Pao2 / Fio2比率。我们的研究结果表明，主治医生在俯卧位的做法上存在很大差异，未来的工作应该考虑以主治医生为中心和全系统的干预措施，作为提高俯卧位率的潜在新目标。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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Role of Attending Practice Variability in Prone Positioning Initiation

Background

Prone positioning is underused, despite mortality benefits. Prior studies highlight that patient-independent factors may influence prone positioning rates, but attending-specific contributions are unknown.

Research Question

Does significant variability in prone positioning rates exist among attending physicians?

Study Design and Methods

This is a retrospective cohort study of 514 adults receiving mechanical ventilation in a tertiary-care medical or surgical ICU from January 1, 2015, through June 30, 2024. Inclusion criteria included Pao₂ to Fio₂ ratio of ≤ 150 with Fio₂ of ≥ 60% and positive end-expiratory pressure of ≥ 5 cm H₂O within 0 to 36 hours and 36 to 72 hours of intubation. The primary outcome was prone positioning within 72 hours of intubation or 24 hours of meeting prone positioning criteria. We hypothesized that attending variability was a significant predictor of prone positioning. We fit a mixed-effects logistic regression model to evaluate attending-level variability in prone positioning use, adjusting for 6 potential patient-centered prone positioning barriers and facilitators (age, BMI, COVID-19 status, code status, Pao₂ to Fio₂ ratio, and vasopressor use) and ICU location (medical or surgical).

Results

Among 514 patients eligible for prone positioning, 87 patients (17%) underwent prone positioning. Significant attending-level variability in prone positioning was noted among the 48 attendings included in the analysis, with risk- and reliability-adjusted rates ranging from 14.9% to 74.2% and a median OR among attending physicians of 2.6 (95% CI, 1.7-5.2). This effect size was associated more strongly with prone positioning than a 30-mm Hg decrease in Pao₂ to Fio₂ ratio. Even among patients with clinical documentation of ARDS on the day of prone positioning eligibility, the median OR among attending physicians was 2.4 (95% CI, 1.5-7.3). Additional patient factors predicting prone positioning included COVID-19 status, code status, and Pao₂ to Fio₂ ratio.

Interpretation

Our results show that large variation in prone positioning practices exists among attending providers, and future work should consider attending-focused and system-wide interventions as potential novel targets to improve prone positioning rates.

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CHEST critical care Critical Care and Intensive Care Medicine, Pulmonary and Respiratory Medicine

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