Demetriades Demetrios, Martin Mathew, Salim Ali, Rhee Peter, Brown Carlos, Chan Linda
Division of Trauma and Surgical Critical Care, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
Ann Surg. 2005 Oct;242(4):512-7; discussion 517-9. doi: 10.1097/01.sla.0000184169.73614.09.
The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries.
Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated.
The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma (<240 vs > or =240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age (<65 > or =65), gender, mechanism of injury, hypotension on admission, and ISS (< or =25 and >25).
A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71-0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44-0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV-V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS >15 (<240 vs > or =240 cases per year) had no effect on outcome in either level I or II centers.
Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.
本研究的目的是调查美国外科医师学会（ACS）创伤中心指定及创伤救治量对特定重伤患者预后的影响。
ACS根据资源、创伤救治量以及教育和研究投入将创伤中心划分为不同级别。创伤中心指定标准是主观的，从未得到验证。
国家创伤数据库研究纳入了年龄>14岁、损伤严重程度评分（ISS）>15、入院时存活且至少有以下一种重伤的患者：主动脉、腔静脉、髂血管、心脏、IV/V级肝损伤、四肢瘫痪或复杂骨盆骨折。比较了I级和II级创伤中心以及同一级别但重伤救治量不同（每年ISS>15的创伤入院病例数<240 vs≥240）的中心之间的预后（死亡率、重症监护病房住院时间和出院时严重残疾情况）。对年龄（<65岁 vs≥65岁）、性别、损伤机制、入院时低血压以及ISS（≤25和>25）进行了预后调整。
共有12254例患者符合纳入标准。总体而言，I级中心的死亡率显著低于II级中心（25.3% vs 29.3%；调整后的优势比[OR]为0.81；95%置信区间[CI]为0.71 - 0.94；P = 0.004），出院时严重残疾率也显著更低（20.3% vs 33.8%，调整后的OR为0.55；95% CI为0.44 - 0.69；P < 0.001）。亚组分析显示，I级创伤中心心血管损伤（N = 2004）和IV - V级肝损伤（N = 1415）的生存率显著高于II级中心（调整后的P值分别为0.017和0.023）。总体而言，I级中心的功能预后显著更好（调整后的P < 0.001）。亚组分析显示，I级中心在复杂骨盆骨折方面的功能预后显著更好（P < 0.001），在其他亚组中也有预后改善的趋势。每年ISS>15的创伤入院病例数（<240 vs≥240例）对I级或II级中心的预后均无影响。
对于伴有高死亡率和不良功能预后的特定损伤患者，I级创伤中心的预后优于较低级别中心。重大创伤入院病例数对I级或II级中心的预后均无影响。这些发现可能对创伤系统规划和根据认证级别进行服务计费具有重要意义。
