Rogers F B, Osler T M, Shackford S R, Martin F, Healey M, Pilcher D
Department of Surgery, University of Vermont, Burlington, Vermont, USA.
J Trauma. 2001 Mar;50(3):409-13; discussion 414. doi: 10.1097/00005373-200103000-00003.
Formalized systems of trauma care are believed to improve outcomes in an urban setting, but little is known of the applicability in a rural setting.
We conducted a population-based analysis of hospital survival after trauma comparing an American College of Surgeons-verified Level I trauma center (TC) with the pooled results of 13 small community hospitals (CH) in a rural state with no formal trauma system. All patients admitted to any hospital within the state of Vermont over a 5-year period (1995-1999) with a trauma discharge diagnosis were included. Elderly patients with isolated femur fractures were excluded from the database. International Classification of Diseases Injury Severity Scores (ICISSs) were calculated for each patient and used to control for injury severity in an omnibus logistic regression model that included age, ICISS, and hospital type (TC vs. CH) as predictors of survival. Patients who died were characterized on the basis of ICISS into "expected" (ICISS < 0.25), "indeterminate" (ICISS = 0.26-0.50), and "unexpected" (ICISS > 0.5).
In 16,354 trauma admissions over the 5-year period in the rural state of Vermont, 370 (2.2%) died. There were 5,964 (36%) admitted to TC. Patients admitted to TC were more injured (ICISS 0.94 vs. 0.96) and had a higher mortality (3.1% vs. 1.8). Overall, care at the CH provided an improved survival (odds ratio = 1.75, 95% confidence internal = 1.31-2.18, p = 0.000). However, in the more severely injured cohort of trauma patients (expected and indeterminate; n = 133), overall survival was higher in the TC (16% CH vs. 38% TC, p = 0.02, chi2). Because the TC was known to provide care equivalent to Major Trauma Outcome Study norms during this time period (Z = -0.03, M = 0.894), we believe this study confirms that trauma care throughout the state is in accordance with national norms.
In a rural state, without a statewide formal trauma system, survival after trauma is no worse at CH than TC when corrected for injury severity and age. Future expenditures of resources might better be concentrated in other areas such as discovery or prehospital care to further improve outcomes.
人们认为创伤护理的规范化系统能够改善城市地区的治疗效果，但对于其在农村地区的适用性却知之甚少。
我们进行了一项基于人群的创伤后医院生存率分析，将一家经美国外科医师学会认证的一级创伤中心（TC）与一个没有正式创伤系统的农村州的13家小型社区医院（CH）的汇总结果进行比较。纳入了佛蒙特州在1995 - 1999年这5年期间因创伤出院诊断而入住该州任何一家医院的所有患者。数据库中排除了单纯股骨骨折的老年患者。为每位患者计算国际疾病分类损伤严重度评分（ICISS），并在一个综合逻辑回归模型中用于控制损伤严重程度，该模型将年龄、ICISS和医院类型（TC与CH）作为生存的预测因素。根据ICISS将死亡患者分为“预期”（ICISS < 0.25）、“不确定”（ICISS = 0.26 - 0.50）和“意外”（ICISS > 0.5）。
在佛蒙特州这个农村州的5年期间的16354例创伤入院患者中，370例（2.2%）死亡。有5964例（36%）入住TC。入住TC的患者受伤更严重（ICISS分别为0.94和0.96）且死亡率更高（3.1%对1.8%）。总体而言，CH的护理提供了更高的生存率（优势比 = 1.75，95%置信区间 = 1.31 - 2.18，p = 0.000）。然而，在受伤更严重的创伤患者队列（预期和不确定；n = 133）中，TC的总体生存率更高（CH为16%，TC为38%，p = 0.02，卡方检验）。因为已知在此期间TC提供的护理等同于重大创伤结局研究规范（Z = -0.03，M = 0.894），我们认为这项研究证实了该州的创伤护理符合国家规范。
在一个没有全州范围正式创伤系统的农村州，在对损伤严重程度和年龄进行校正后，CH的创伤后生存率并不比TC差。未来资源的支出可能更好地集中在其他领域，如发现或院前护理，以进一步改善治疗效果。
