Trooskin S Z, Copes W S, Bain L W, Santora T A
Department of Surgery, Medical College of Pennsylvania, Philadelphia 19129, USA.
J Trauma. 1999 Dec;47(6):1018-26; discussion 1026-7. doi: 10.1097/00005373-199912000-00006.
To apply case-matching methodology to a statewide trauma registry to identify for peer review one trauma center's patients with "unexpected" survival deaths, complications or prolonged length of stay in hospital (H-LOS) or in Intensive Care Unit (ICU-LOS).
Matching patients were defined by mechanism of injury, age, physiology and intubation status on emergency department admission, preexisting conditions, and the pattern and severity of anatomic injury. Matches for one trauma center's 1997 patients (TCP) were sought from other centers' patients (SWP) submitted to the statewide registry from October 1, 1993, though December 31, 1997. A minimum of 20 SWP matches was required for creating a matching group. TCP were compared with matching SWP for survival, H-LOS, and ICU-LOS and the occurrence of complications. Unexpected survivors and deaths identified by matching (by using the standard 50% cutpoint) were also evaluated by TRISS and the American College of Surgeon's Committee on Trauma. A patient whose complications occurred in less than 10% of matching patients or whose H-LOS or ICU-LOS exceeded the 90th percentile of its matching SWP were also designated for peer review.
The potential matching pool included 69,660 SWP. At least one SWP match was found for 565 (92.9%) of the 608 TCPs. The average, median, and maximum number of matches were 917.6, 235, and 6,504 patients, respectively. The 451 patients with 20 or more SWP matches were further studied. Case matching and TRISS agreed on the identification of five unexpected deaths; the American College of Surgeon's Committee on Trauma agreed on four of five. Peer review included, however, that none of the deaths were clinically unexpected. Case matching identified 14 TCP with 29 complications; only 4 of those patients had undergone concurrent peer review. Retrospective review revealed two preventable and potentially seven preventable complications. There were 35 TCP patients with prolonged H-LOS and 24 with prolonged ICU-LOS. Peer review of those cases identified that complications and problems related to discharge planning contributed to the prolonged ICU-LOS (20.8% and 25.0%) and the H-LOS (20.% and 48.6%), respectively.
Peer review of patients identified by case-matching methodology uncovered opportunities for system improvement that were missed by the concurrent performance improvement process. This method may also allow identification of anticipated H-LOS and ICU-LOS to promote earlier discharge.
将病例匹配方法应用于全州创伤登记系统，以挑选出一家创伤中心中具有“意外”存活死亡、并发症或住院时间延长（H-LOS）或重症监护病房住院时间延长（ICU-LOS）的患者进行同行评审。
通过损伤机制、年龄、急诊科入院时的生理状况和插管状态、既往疾病以及解剖损伤的类型和严重程度来定义匹配患者。从1993年10月1日至1997年12月31日提交至全州登记系统的其他中心患者（SWP）中寻找与一家创伤中心1997年患者（TCP）相匹配的病例。创建一个匹配组至少需要20例SWP匹配病例。将TCP与匹配的SWP在存活情况、H-LOS、ICU-LOS以及并发症发生情况方面进行比较。通过匹配（使用标准的50%切点）确定的意外存活者和死亡病例也由TRISS和美国外科医师学会创伤委员会进行评估。并发症发生率低于10%的匹配患者，或者H-LOS或ICU-LOS超过其匹配SWP第90百分位数的患者也被指定进行同行评审。
潜在的匹配库包含69,660例SWP。在608例TCP中，有565例（92.9%）至少找到了一例SWP匹配病例。匹配病例的平均、中位数和最大数量分别为917.6例、235例和6,504例。对451例有20例或更多SWP匹配病例的患者进行了进一步研究。病例匹配和TRISS在确定5例意外死亡病例方面达成一致；美国外科医师学会创伤委员会在5例中有4例达成一致。然而，同行评审发现这些死亡病例在临床上均无意外情况。病例匹配确定了14例TCP患者有29种并发症；其中只有4例患者同时接受了同行评审。回顾性审查发现了2例可预防和可能7例可预防的并发症。有35例TCP患者H-LOS延长，24例患者ICU-LOS延长。对这些病例的同行评审发现，与出院计划相关的并发症和问题分别导致了ICU-LOS延长（20.8%和25.0%）以及H-LOS延长（20.%和48.6%）。
通过病例匹配方法确定的患者进行同行评审揭示了并发性能改进过程中遗漏的系统改进机会。这种方法还可能有助于确定预期的H-LOS和ICU-LOS，以促进更早出院。
