[A clinical study of high dependency units to reduce ICU readmission rates in patients with severe liver disease]
- PMID: 37337130
- DOI: 10.3760/cma.j.cn501113-20230214-00056
[A clinical study of high dependency units to reduce ICU readmission rates in patients with severe liver disease]
Abstract
Objective: To investigate the real-world difference in the ICU readmission rate between the high-dependency unit (HDU) and the general ward so as to reflect the role of HDU in the diagnosis and management of patients with SLD. Methods: Patients with severe liver disease who were consecutively enrolled were step-downed to HDU and general wards in the ICU of the Fifth Medical Center of the People's Liberation Army General Hospital between July 2017 and December 2021. The main liver function indicators, MELD scores, and other were compared between the two groups. SLD severity, ICU readmission rates, and others differences were analyzed among the patients transferred to different wards. The HDU role was clarified for SLD patients' grade management. The area under the curve of the receiver operating characteristic curve (AUROC) was used to calculate and explore the feasibility of a baseline Model for End-Stage Liver Disease (MELD) score to define the treatment scope of HDU. Results: The SLD group of patients who were transferred to HDU had significantly higher levels of the international normalized ratio, bilirubin, alanine aminotransferase, MELD score, and other factors compared to those in the general ward (P < 0.05). 70.7% of SLD patients in the HDU group had a MELD score > 17, while 61.9% of SLD patients in the general ward group had a MELD score ≤ 17. The overall ICU readmission rate in this cohort was 11.4%. The ICU readmission rate was significantly higher with a MELD score of > 23 (20.0%) than that with a MELD score of ≤ 23 (8.6%) in patients with SLD, according to the MELD score quartile P75 (P = 0.020). The ICU readmission rate was 8.2% when MELD score ≤ 23, and 9.1% when MELD score>23 in the HDU group, with no statistically significant difference (P = 1.000). However, in the general ward group, the ICU readmission rate in patients with a MELD score ≤ 23 was 8.8%, and when the MELD score was >23, the ICU readmission rate significantly increased to 36.4% (P = 0.001). The optimal cut-off value of the MELD score for predicting ICU readmission in patients with SLD in the general ward group was 23.5. Conclusion: The high-dependency unit can better undertake ICU step-down patients with SLD and significantly reduce the ICU readmission rate with MELD scores > 23 in practice. Additionally, ICU step-down SLD patients with a MELD score > 23 are suitable for transfer to HDU treatment.
目的： 探讨真实世界中高度依赖病房（HDU）和普通病房中重症肝病（SLD）患者重症监护病房（ICU）重返率的差异，反映HDU在SLD患者诊疗管理中的作用。 方法： 连续纳入解放军总医院第五医学中心ICU从2017年7月至2021年12月降阶梯至HDU及普通病房的重症肝病患者，比较两组间的主要肝功能指标、终末期肝病模型（MELD）评分等，分析转入不同病房的SLD患者病情严重程度、ICU重返率等的差异，阐明HDU病房在SLD患者等级病房管理中的作用；采用受试者操作特征曲线计算曲线下面积(AUROC)，探讨基线MELD评分界定HDU收治范围的可行性。 结果： SLD患者转入HDU时国际标准化比值、总胆红素、丙氨酸转氨酶、MELD评分等水平均显著高于转入普通病房组（P值均< 0.05）。转入HDU组中有70.7%的SLD患者MELD评分> 17，而普通病房组中有61.9%的SLD患者MELD评分≤17。本队列总体ICU重返率为11.4%，按照MELD评分四分位数P(75)分组，MELD评分>23的SLD患者ICU重返率（20.0%）显著高于MELD评分≤23的SLD患者（8.6%）（P = 0.020）。HDU组MELD评分≤23时ICU重返率为8.2%，MELD评分>23时ICU重返率为9.1%，差异无统计学意义（P = 1.0），而普通病房组MELD评分≤23时患者ICU重返率为8.8%，MELD评分>23时ICU重返率显著升高至36.4%（P = 0.001）。MELD评分预测普通病房组SLD患者重返ICU的最佳临界值为23.5。 结论： HDU在实践中较好地承接了肝病病情较重的ICU降阶梯SLD患者，并显著降低MELD评分>23的ICU降阶梯SLD患者的ICU重返率。MELD评分>23的ICU降阶梯SLD患者适合转入HDU救治。.
Keywords: Decompensated liver cirrhosis; High dependency unit; Intensive care; Intensive care unit readmission rate; Liver failure; Severe liver disease.
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