Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
J Am Coll Surg. 2010 Dec;211(6):804-11. doi: 10.1016/j.jamcollsurg.2010.08.014. Epub 2010 Oct 30.
Injured patients cared for in trauma centers have a lower risk of death than those cared for in nontrauma centers. However, many patients are transported to a non-trauma center after injury (undertriaged) and require transfer to trauma center care. Previous analyses of undertriage focused only on survivors to trauma center care and were potentially subject to survivor bias. Using a novel population-based design, we evaluated the true mortality cost of undertriage.
We used a retrospective cohort design and included all severely injured patients surviving to reach an emergency department within the province of Ontario, Canada. Those patients who were triaged to a non-trauma center as their first hospital exposure were the Undertriage cohort. Undertriage cohort patients were either transferred to a trauma center (Transfer cohort) or died before transfer could be accomplished (emergency department-death cohort). Patients that were transported directly from the scene of injury to a trauma center represented the Direct cohort. Thirty-day mortality in undertriaged patients was analyzed using two approaches: allowing for survivor bias (Transfer versus Direct) and without survivor bias (Undertriage versus Direct).
Among 11,398 patients, 66% were transported directly to a trauma center and 30% were transferred. Four percent died before transfer (22% of all deaths). Reproducing approaches that ignore survivor bias, mortality in the Transfer and Direct cohorts was equivalent. However, unbiased assessment demonstrated that mortality was significantly higher in the Undertriage cohort than the Direct cohort (odds ratio = 1.24; 95% CI, 1.10-1.40).
Undertriage after major trauma is associated with substantial mortality. These data suggest a need to design strategies to improve triage to trauma center.
在创伤中心接受治疗的受伤患者的死亡风险低于在非创伤中心接受治疗的患者。然而，许多患者在受伤后被送往非创伤中心（分诊不足），需要转至创伤中心接受治疗。先前对分诊不足的分析仅关注到达创伤中心的幸存者，并且可能存在幸存者偏差。使用一种新颖的基于人群的设计，我们评估了分诊不足的真实死亡率代价。
我们使用回顾性队列设计，纳入了在加拿大安大略省到达急诊室的所有严重受伤患者。那些被分诊到非创伤中心作为其首次医院就诊的患者为分诊不足队列。分诊不足队列的患者要么被转至创伤中心（转院队列），要么在转院之前死亡（急诊死亡队列）。从受伤现场直接被送往创伤中心的患者代表直接转院队列。使用两种方法分析分诊不足患者的 30 天死亡率：考虑幸存者偏差（转院与直接）和不考虑幸存者偏差（分诊不足与直接）。
在 11398 名患者中，66%被直接送往创伤中心，30%被转院。4%的患者在转院前死亡（所有死亡患者的 22%）。重现忽略幸存者偏差的方法时，转院和直接转院队列的死亡率相当。然而，无偏差评估表明，分诊不足队列的死亡率明显高于直接转院队列（优势比=1.24；95%置信区间，1.10-1.40）。
在重大创伤后分诊不足与大量死亡相关。这些数据表明需要设计策略来改进创伤中心的分诊。
