Stengel D, Seifert J, Braatz F, Beneker J, Ekkernkamp A, Matthes G
Abteilung für Unfall- und Wiederherstellungschirurgie, Klinik und Poliklinik für Chirurgie, Ernst-Moritz-Arndt-Universität Greifswald.
Unfallchirurg. 2005 Jul;108(7):551-8. doi: 10.1007/s00113-005-0935-y.
We studied the quality and quantity of information leading to the emergency physician's decision to intubate severely injured patients on scene. Our aim was to assess intuitive aspects of clinical decision making. The experiment involved three different phases, with a fourth phase examining retest reliability. We used trauma register data from 98 patients. Based on various parameters (physiological data, injury assessment on scene, definite injury pattern), three emergency surgeons were requested to decide on the need for endotracheal intubation.We applied multivariate logistic regression to estimate the likelihood of intubation given certain clinical characteristics or combinations of characteristics. We compared the participants' decisions to those made by "true" emergency physicians on scene. Kappa statistics marked inter-observer agreement beyond chance. The Glasgow Coma Scale (GCS) was the only single predictor of intubation in the ideal test setting (area under the receiver operating characteristics curve [AUC] >98%) as well as on scene (AUC 0.85, 95% confidence interval 0.78-0.92). There was no difference between the discriminatory features of the single item GCS and complex multivariate models that included anatomically defined injury scales (best model in phase 2: AUC 0.96, best model in phase 3: AUC 0.98). Overall inter-observer agreement was substantial in phase 1 (kappa=0.74), fair to moderate in phase 2 (kappa=0.49) and slight to fair in phase 3 (kappa=0.23). Retest reliability ranged from 51% to 91%. Doctors give priority to only a small part of the information available in deciding for or against a particular intervention.
我们研究了促使急诊医生决定在现场对重伤患者进行气管插管的信息质量和数量。我们的目的是评估临床决策的直观方面。该实验包括三个不同阶段，第四阶段检验重测信度。我们使用了98例患者的创伤登记数据。基于各种参数（生理数据、现场损伤评估、明确的损伤模式），要求三名急诊外科医生决定是否需要进行气管插管。我们应用多变量逻辑回归来估计在某些临床特征或特征组合情况下进行插管的可能性。我们将参与者的决策与现场“真正的”急诊医生的决策进行了比较。kappa统计显示观察者间的一致性超出了偶然因素。格拉斯哥昏迷量表（GCS）是理想测试环境（受试者工作特征曲线下面积[AUC]>98%）以及现场（AUC 0.85，95%置信区间0.78 - 0.92）中插管的唯一单一预测指标。单项GCS与包含解剖学定义损伤量表的复杂多变量模型的鉴别特征之间没有差异（第二阶段最佳模型：AUC 0.96，第三阶段最佳模型：AUC 0.98）。观察者间的总体一致性在第一阶段较高（kappa = 0.74），在第二阶段为中等（kappa = 0.49），在第三阶段为轻微到中等（kappa = 0.23）。重测信度范围为51%至91%。医生在决定支持或反对特定干预措施时，仅优先考虑可用信息的一小部分。
