Roudsari Bahman S, Nathens Avery B, Cameron Peter, Civil Ian, Gruen Russel L, Koepsell Thomas D, Lecky Fiona E, Lefering Rolf L, Liberman Moishe, Mock Charles N, Oestern Hans-Jörg, Schildhauer Thomas A, Waydhas Christian, Rivara Frederick P
Department of Epidemiology, University of Texas, School of Public Health, Dallas, USA.
Injury. 2007 Sep;38(9):993-1000. doi: 10.1016/j.injury.2007.03.028. Epub 2007 Jul 20.
Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients' outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems.
Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP) <90mmHg) and early trauma fatality rate (i.e. death during the first 24h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes.
After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73-1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54-0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems.
These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.
鉴于近期全球对发展院前创伤护理的重视，我们开展了一项多中心研究，以比较在配备技术人员操作的高级生命支持（ALS）和医生操作（Doc-ALS）紧急医疗服务（EMS）系统的国家内部及之间创伤患者的结局。这些环境代表了高收入国家中具有更先进院前创伤护理系统的院前护理连续体。
五个拥有ALS-EMS系统的国家和四个拥有Doc-ALS EMS系统的国家从其国家或地方创伤登记处为我们提供了去识别化的患者层面数据。使用广义线性潜在和混合模型来比较ALS和Doc-ALS EMS系统之间的急诊科（ED）休克率（收缩压（SBP）<90mmHg）和早期创伤死亡率（即入院后首24小时内死亡）。使用逻辑回归来比较不同国家之间感兴趣的结局，并考虑患者结局的系统内相关性。
在对患者年龄、性别、损伤类型和机制、损伤严重程度评分及现场SBP进行调整后，Doc-ALS和ALS系统之间的ED休克率无显著差异（OR：1.16，95%CI：0.73-1.91）。然而，与ALS EMS系统相比，Doc-ALS EMS系统的早期创伤死亡率显著更低（OR：0.70，95%CI：0.54-0.91）。此外，我们发现即使在具有相似类型EMS系统的国家之间，患者结局也存在相当大的异质性。
这些发现表明，派遣医生到现场的院前创伤护理系统可能与较低的早期创伤死亡率相关，但不一定在其他临床指标上有显著更好的结局。这些发现背后的原因值得进一步研究。
