Cornwell Edward E, Chang David C, Phillips Judith, Campbell Kurtis A
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
Arch Surg. 2003 Aug;138(8):838-43. doi: 10.1001/archsurg.138.8.838.
With advances in surgical care, the occurrences of major adverse outcomes have become a rare event. The effect of a surgical service can be more comprehensively evaluated by following the Donabedian model, looking at the triad of structure, process, and outcome. It is hypothesized that the implementation of a focused program commitment at a trauma center is associated with improvements in process of care and patient outcomes.
Evaluation of prospectively collected information in a trauma registry for the 3-year periods immediately before (1995-1997) and after (1999-2001) the implementation (in 1998) of the full-time trauma service.
Level I university-affiliated trauma center.
Patients meeting criteria for major trauma.
The implementation of a full-time trauma service, featuring 24-hour in-house attending coverage, dedicated trauma admitting unit, regular trauma core curriculum, regular multidisciplinary quality assurance meetings, and state designation for level I status.
Process of care measures, including time in the emergency department (ED) and trauma "bypass" hours (ie, time spent in the trauma resuscitation area). Outcome measures, including lengths of stay, overall mortality and mortality, excluding ED deaths.
The total number of patients with major trauma increased from 2240 (1995-1997) to 2513 (1999-2001). The average time in the ED for patients going to the operating room, intensive care unit, and observation wards all decreased significantly (84 vs 52 minutes, 197 vs 118 minutes, and 300 vs 140 minutes, respectively; all with P<.01). The number of hours that the trauma center was closed owing to ED overcrowding also decreased significantly, from 56 to 2.7 hours per month (P<.01). After excluding ED deaths, there was a trend on bivariate analyses toward lower overall mortality rates (4.5% vs 3.4%, P =.07) and mortality rates among patients with severe head injury (23.8% vs 17.2%, P =.07). On further analyses with multiple logistic regression, controlling for age, Injury Severity Score, Abbreviated Injury Score (for a head injury), and admission blood pressure, the later period is associated with a 31% decrease in overall odds of death (P =.047) and a 42% decrease in odds of death among patients with severe head injury (an Abbreviated Injury Score, >or=3; P =.03).
The implementation of a full-time trauma service is associated with improved timeliness of triage and therapeutic interventions and improved patient outcomes.
随着外科治疗的进展，重大不良后果的发生已成为罕见事件。通过遵循多纳贝迪安模型，审视结构、过程和结果这三个要素，可以更全面地评估外科服务的效果。据推测，在创伤中心实施一项重点项目承诺与护理过程及患者结局的改善相关。
对前瞻性收集的信息进行评估，这些信息来自创伤登记处，涵盖全职创伤服务实施前（1995 - 1997年）和实施后（1999 - 2001年）的3年期间（1998年实施）。
一级大学附属医院创伤中心。
符合重大创伤标准的患者。
实施全职创伤服务，其特点包括24小时内部主治医生值班、专门的创伤收治单元、定期的创伤核心课程、定期的多学科质量保证会议以及一级创伤中心的州级指定。
护理过程指标，包括在急诊科的时间以及创伤“旁路”时间（即在创伤复苏区花费的时间）。结局指标，包括住院时间、总死亡率以及不包括急诊科死亡的死亡率。
重大创伤患者总数从2240例（1995 - 1997年）增加到2513例（1999 - 2001年）。前往手术室、重症监护病房和观察病房的患者在急诊科的平均时间均显著减少（分别为84分钟对52分钟、197分钟对118分钟以及300分钟对140分钟；均P <.01）。创伤中心因急诊科过度拥挤而关闭的小时数也显著减少，从每月56小时降至2.7小时（P <.01）。排除急诊科死亡病例后，双变量分析显示总体死亡率有降低趋势（4.5%对3.4%，P =.07），重度颅脑损伤患者的死亡率也有降低趋势（23.8%对17.2%，P =.07）。在进一步进行多因素逻辑回归分析时，控制年龄、损伤严重程度评分、简明损伤评分（针对颅脑损伤）和入院血压后，后期总体死亡几率降低31%（P =.047），重度颅脑损伤患者（简明损伤评分≥3）的死亡几率降低42%（P =.03）。
实施全职创伤服务与分诊和治疗干预及时性的改善以及患者结局的改善相关。
