Lee John C, Rogers Frederick B, Horst Michael A
Trauma Center, Lancaster General Hospital, Lancaster, PA 17602, USA.
J Trauma. 2010 Nov;69(5):1147-52; discussion 1152-3. doi: 10.1097/TA.0b013e3181f5a867.
Critical care-trained trauma surgeons are the ideal care provider for severely injured patients. This "captain of the ship" (COS) assumes complete responsibility of the patient, from initial resuscitation to eventual discharge. Unlike American College of Surgeons-verified Level I centers, many nonacademic, community hospital trauma centers use a more fragmented approach, with care in the intensive care unit (ICU) delegated to a committee of multiple specialists. We hypothesized that dedicated trauma intensivists as COS in a community hospital could improve ICU outcome.
Beginning from September 2005, dedicated full-time trauma intensivists, without any resident coverage, assumed primary responsibility of all trauma patients admitted to a Level II Pennsylvania state verified trauma center. The ICU care was uninterrupted 24 hours a day, 365 days a year. Subspecialty consultations, for recommendations in care only, were selectively obtained as clinically indicated. We compared the 3 years before the implementation of the COS model (PRE: 2003-2005) with the 3 years after the model (POST: 2006-2008). A p-value ≤ 0.05 was considered significant.
There were equal numbers of patients admitted to the ICU setting in both the periods. In the PRE and POST periods, both age (46.9 years vs. 52.4 years; p < 0.001) and Injury Severity Score (16.1 vs. 16.7; p = 0.01) were of significance. We observed significant differences in ventilator days (mean, 8 days vs. 6 days; p = 0.002) and mean ICU days (4.9 days vs. 4.4 days; p < 0.001) across the study periods. Days to tracheostomy also achieved statistical significance (9.1 vs. 8.1; p = 0.03). The number of medical consults decreased by 19% in the POST group (p < 0.001). Hospital stay days were not statistically different (7.4 vs. 7.2; p = 0.18). After adjusting for higher age and Injury Severity Score in the POST period, we noted no difference in the expected mortality rate.
A trauma intensivist-driven model can be successfully adopted in a nonacademic community trauma program, without the need for a residency program. A decentralized ICU care model produces inefficiencies, diminishes the role of the trauma service, and decreases the overall throughput of trauma patients.
接受过重症监护培训的创伤外科医生是重伤患者的理想护理提供者。这位“船长”（COS）对患者承担全部责任，从初始复苏到最终出院。与美国外科医师学会认证的一级中心不同，许多非学术性的社区医院创伤中心采用更为分散的方法，重症监护病房（ICU）的护理工作委托给由多名专家组成的委员会。我们假设在社区医院中由专门的创伤重症医生担任COS可以改善ICU的治疗效果。
从2005年9月开始，由专门的全职创伤重症医生承担所有入住宾夕法尼亚州二级创伤中心的创伤患者的主要护理责任，不设住院医师。ICU护理全年无休，每天24小时不间断。仅在临床需要时选择性地寻求专科会诊以获取护理建议。我们将COS模式实施前的3年（PRE：2003 - 2005年）与实施后的3年（POST：2006 - 2008年）进行了比较。p值≤0.05被认为具有统计学意义。
两个时期入住ICU的患者数量相等。在PRE期和POST期，年龄（46.9岁对52.4岁；p < 0.001）和损伤严重程度评分（16.1对16.7；p = 0.01）均具有统计学意义。我们观察到在整个研究期间，呼吸机使用天数（平均，8天对6天；p = 0.002）和平均ICU住院天数（4.9天对4.4天；p < 0.001）存在显著差异。气管切开的天数也具有统计学意义（9.1对8.1；p = 0.03）。POST组的内科会诊次数减少了19%（p < 0.001）。住院天数无统计学差异（7.4对7.2；p = 0.18）。在对POST期较高的年龄和损伤严重程度评分进行调整后，我们发现预期死亡率没有差异。
在非学术性社区创伤项目中可以成功采用由创伤重症医生主导的模式，无需住院医师培训项目。分散的ICU护理模式会产生效率低下的问题，削弱创伤服务的作用，并降低创伤患者的整体周转率。
