Utter Garth H, Maier Ronald V, Rivara Frederick P, Mock Charles N, Jurkovich Gregory J, Nathens Avery B
Department of Surgery, Harborview Medical Center, and the Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.
J Trauma. 2006 Mar;60(3):529-35; discussion 535-37. doi: 10.1097/01.ta.0000204022.36214.9e.
Trauma systems decrease injury-related mortality, but not all systems have the same configuration. In some systems, nearly all acute care hospitals participate to the extent that their resources allow (inclusive systems), whereas in others, relatively few high-level centers participate (exclusive systems). We postulate that inclusive systems assure that severely injured patients are more likely to be triaged to a level I or II regional trauma center, and this greater degree of participation would lead to lower mortality.
We used administrative discharge data for 2001 in 24 states with formal systems, and we included all urgently hospitalized adults with an Injury Severity Score>or=16. We categorized states by trauma system configuration ("exclusive", "more inclusive", "most inclusive") based on the proportion of all hospitals designated as a Level I through V trauma center (0-13%, 14-37%, 38-100%, respectively). We compared the rates of triage to a regional trauma center and inpatient death in inclusive states relative to exclusive states, while adjusting for patient- and state-level factors.
Out of 61,496 patients, 40,706 (66.2%) were hospitalized at regional trauma centers. Inpatient mortality was 14.7%. After adjusting for patient age, primary payer status, and system maturity, the odds of triage to a regional trauma center were similar in inclusive and exclusive systems. After adjusting for primary payer status, mechanism of injury, and system maturity, the odds of death were similar in more inclusive and exclusive systems (odds ratio, 0.93; 95% confidence interval, 0.80-1.08) but were significantly lower in the most inclusive systems (odds ratio, 0.77; 95% confidence interval, 0.60-0.99).
Severely injured trauma patients have greater inpatient survival in inclusive trauma systems even though they are no more likely to be hospitalized at a regional trauma center. Consideration should be given to continuing implementation of systems with an inclusive configuration, especially in light of other theoretical benefits of these systems, such as better dispersing of trauma care resources in the event of natural disasters or terrorist events.
创伤系统可降低与损伤相关的死亡率，但并非所有系统都具有相同的配置。在一些系统中，几乎所有急症护理医院都会在其资源允许的范围内参与（包容性系统），而在其他系统中，只有相对较少的高级别中心参与（排他性系统）。我们推测，包容性系统可确保重伤患者更有可能被分诊到一级或二级区域创伤中心，而这种更高程度的参与将导致更低的死亡率。
我们使用了24个拥有正式系统的州2001年的行政出院数据，并纳入了所有损伤严重程度评分≥16分的紧急住院成人患者。我们根据被指定为一级至五级创伤中心的所有医院的比例（分别为0-13%、14-37%、38-100%），将这些州按创伤系统配置（“排他性”、“更具包容性”、“最具包容性”）进行分类。我们比较了包容性州与排他性州分诊到区域创伤中心的比率和住院患者死亡率，同时对患者和州层面的因素进行了调整。
在61496例患者中，40706例（66.2%）在区域创伤中心住院。住院死亡率为14.7%。在对患者年龄、主要支付方状态和系统成熟度进行调整后，包容性系统和排他性系统分诊到区域创伤中心的几率相似。在对主要支付方状态、损伤机制和系统成熟度进行调整后，更具包容性的系统和排他性系统的死亡几率相似（优势比，0.93；95%置信区间，0.80-1.08），但在最具包容性的系统中显著更低（优势比，0.77；95%置信区间，0.60-0.99）。
重伤创伤患者在包容性创伤系统中的住院生存率更高，尽管他们在区域创伤中心住院的可能性并没有更大。应考虑继续实施具有包容性配置的系统，特别是鉴于这些系统的其他理论优势，例如在自然灾害或恐怖事件发生时更好地分散创伤护理资源。
