Helling Thomas S, Davit Flavia, Edwards Kim
Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, Pennsylvania, USA.
J Trauma. 2010 Dec;69(6):1362-6. doi: 10.1097/TA.0b013e3181d75250.
Rural trauma has been associated with higher mortality because of a number of geographic and demographic factors. Many victims, of necessity, are first cared for in nearby hospitals, many of which are not designated trauma centers (TCs), and then transferred to identified TCs. This first echelon care might adversely affect eventual outcome. We have sought to examine the fate of trauma patients transferred after first echelon hospital evaluation and treatment.
All trauma patients transferred (referred group) to a Pennsylvania Level I TC located in a geographically isolated and rural setting during a 68-month period were retrospectively compared with patients transported directly to the TC (direct group). Outcome measures included mortality, complications, physiologic parameters on arrival at the TC, operations within 6 hours of arrival at the TC, discharge disposition from the TC, and functional outcome. Patients with an injury severity score <9 and those discharged from the TC within 24 hours were excluded.
During the study period, 2,388 patients were transported directly and 529 were transferred. Mortality between groups was not different: 6% (referred) versus 9% (direct), p = 0.074. Occurrence of complications was not different between the two groups. Physiologic parameters (systolic blood pressure, heart rate, and Glasgow Coma Scale score) at admission to the Level I TC differed statistically between the two groups but seemed near equivalent clinically. Sixteen percent of patients required an operative procedure within 6 hours in the direct group compared with 10% in the referral group (p = 0.001). Hospital and intensive care unit length of stay were less in the referred group, although this was not statistically significant. Performance scores on discharge were equivalent in all categories except transfer ability. Time from injury to definitive care (TC) was 1.6 hours ± 3.0 hours in the direct group and 5.3 hours ± 3.8 hours in the referred group (p < 0.0001). The most common procedure performed at first echelon hospitals was airway control (55% of referred patients).
In this rural setting, care at first echelon hospitals, most (95%) of which were not designated TCs, seemed to augment, rather than detract from, favorable outcomes realized after definitive care at the TC.
由于一些地理和人口因素，农村创伤与更高的死亡率相关。许多受害者必须首先在附近的医院接受治疗，其中许多医院并非指定的创伤中心（TCs），然后再被转至确定的创伤中心。这种第一梯队的护理可能会对最终结果产生不利影响。我们试图研究在第一梯队医院评估和治疗后被转运的创伤患者的转归情况。
回顾性比较在68个月期间被转运至位于地理上孤立的农村地区的宾夕法尼亚州一级创伤中心的所有创伤患者（转诊组）与直接被送至该创伤中心的患者（直接组）。结局指标包括死亡率、并发症、抵达创伤中心时的生理参数、抵达创伤中心后6小时内的手术情况、从创伤中心出院的处置方式以及功能结局。排除损伤严重程度评分<9分以及在创伤中心24小时内出院的患者。
在研究期间，2388例患者直接被转运，529例患者被转诊。两组之间的死亡率无差异：6%（转诊组）对9%（直接组），p = 0.074。两组之间并发症的发生率无差异。一级创伤中心入院时的生理参数（收缩压、心率和格拉斯哥昏迷量表评分）在两组之间有统计学差异，但临床情况似乎相近。直接组16%的患者在6小时内需要进行手术，而转诊组为10%（p = 0.001）。转诊组的住院时间和重症监护病房住院时间较短，尽管这在统计学上不显著。除转移能力外，所有类别出院时的表现评分相当。直接组从受伤到确定性治疗（创伤中心）的时间为1.6小时±3.0小时，转诊组为5.3小时±3.8小时（p < 0.0001）。第一梯队医院最常进行的操作是气道控制（55%的转诊患者）。
在这个农村地区，第一梯队医院（其中大多数（95%）并非指定的创伤中心）的护理似乎增强而非降低了在创伤中心进行确定性治疗后实现的良好结局。
