评估法国医生配备的紧急医疗服务在重大创伤患者分诊中的表现。
Evaluation of the performance of French physician-staffed emergency medical service in the triage of major trauma patients.
机构信息
Critical Care & Anesthesiology Department (S.R.H.), AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; Critical Care & Anesthesiology Department (S.R.H.), AP-HP, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, Hôpitaux Universitaires Paris Sud, F-94275, Le Kremlin Bicêtre, France; University Paris Diderot (T.G.), Sorbonne Paris Cité, F-75018, Paris, France; Critical Care & Anesthesiology Department, AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; SMUR (F.X.D.), AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; Urgences - SMUR department (J.T.), Hôpital Lariboisière, 2 rue Ambroise Paré, 75475 Paris, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; University Paris Sud (A.H.), F-94275, Le Kremlin Bicêtre, France; Critical Care & Anesthesiology Department, AP-HP, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, Hôpitaux Universitaires Paris Sud, F-94275, Le Kremlin Bicêtre, France; University Pierre Marie Curie (M.R.), F 75013, Paris France; UR 10 UPMC, Paris VI, Critical Care & Anesthesiology Department, AP-HP, Hôpital Pitie Salpétrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, Hôpitaux Universitaires Pitié Salpétrière, F 75013, Paris, France; University Paris Sud (J.D.), F-94275, Le Kremlin Bicêtre, France; Equipe universitaire 3509 Paris VII, Paris XI, Paris XIII; Critical Care & Anesthesiology Department, AP-HP, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, Hôpitaux Universitaires Paris Sud, F-94275, Le Kremlin Bicêtre, France; University Paris Diderot (J.M.), Sorbonne Paris Cité, F-75018, Paris, France; Critical Care & Anesthesiology Departmen
出版信息
J Trauma Acute Care Surg. 2014 Jun;76(6):1476-83. doi: 10.1097/TA.0000000000000239.
BACKGROUND
Proper prehospital triage of trauma patients is a cornerstone for the process of care of trauma patients. In France, emergency physicians perform this process according to a national triage algorithm called Vittel Triage Criteria (VTC), introduced in 2002 to help the triage decision-making process. The aim of this two-center study was to evaluate the performance of the triage process based on the VTC to identify major trauma patients in the Paris area.
METHODS
This was a retrospective analysis of two cohorts. The first cohort consisted of all patients admitted between January 2011 and September 2012 in two trauma referral centers in the region of Paris (Ile de France) and allowed estimation of overtriage. Undertriage was assessed in a second cohort made up of all prehospital trauma interventions from one emergency medicine sector during the same period. Adequate triage was defined by a direct admission of patients with an Injury Severity Score (ISS) greater than 15 into one of the regional trauma centers, and undertriage was defined as an initial nonadmission to a trauma center. Overtriage was defined by an admission of patients with an ISS of 15 or lower to a trauma center. The performance of the VTC was evaluated according to a strict to-the-letter application of the VTC and termed as theoretical triage. Logistic regression was performed to identify VTC criteria able to predict major trauma.
RESULTS
Among 998 admitted patients of the first cohort, 173 patients (17%) were excluded because they were not directly admitted in the first 24 hours. In the first cohort (n = 825), adequate triage was 58% and overtriage was 42%. In the second cohort (n = 190), adequate triage was 40%, overtriage was 60%, and undertriage was less than 1%. Theoretical triage generated a nonsignificantly lower overtriage and a higher undertriage compared with observed triage. The most powerful predictors of major trauma were paralysis (odds ratio [OR,] 0.09; 95% confidence interval [CI], 0.03-0.22), flail chest (OR, 0.1; 95% CI, 0.01-0.03), and Glasgow Coma Scale (GCS) score of less than 13 (OR, 0.28; 95% CI, 0.17-0.45), whereas global assessments of speed and mechanism alone were poor predictors (positive likelihood ratio, 0.92-1.4).
CONCLUSION
In the Paris area, the French physician-based prehospital triage system for patients with suspicion of major trauma showed a high rate of overtriage and a low rate of undertriage. Criteria of global assessment of speed and mechanism alone were poor predictors of major trauma.
背景
对创伤患者进行适当的院前分诊是创伤患者护理过程的基石。在法国，急诊医生根据一种名为维特尔分诊标准（VTC）的全国分诊算法进行分诊，该算法于 2002 年引入，旨在帮助分诊决策过程。本两项中心研究的目的是评估基于 VTC 的分诊流程，以识别巴黎地区的重大创伤患者。
方法
这是对两个队列的回顾性分析。第一队列包括 2011 年 1 月至 2012 年 9 月期间在巴黎地区（法兰西岛）的两个创伤转诊中心入院的所有患者，该队列可评估过度分诊。在同一时期，对一个急救医学部门的所有院前创伤干预措施进行了第二队列评估，以评估分诊不足。充分分诊定义为损伤严重程度评分（ISS）大于 15 的患者直接收入其中一个区域创伤中心，分诊不足定义为最初未收入创伤中心。分诊过度定义为 ISS 为 15 或更低的患者收入创伤中心。根据 VTC 的严格字面应用评估了 VTC 的性能，并将其称为理论分诊。Logistic 回归用于确定能够预测重大创伤的 VTC 标准。
结果
在第一队列的 998 名入院患者中，173 名患者（17%）因在 24 小时内未直接入院而被排除在外。在第一队列（n=825）中，充分分诊率为 58%，过度分诊率为 42%。在第二队列（n=190）中，充分分诊率为 40%，过度分诊率为 60%，分诊不足率小于 1%。与观察分诊相比，理论分诊导致过度分诊的发生率略有降低，而分诊不足的发生率略有升高。主要创伤的最强预测因素是瘫痪（比值比 [OR]，0.09；95%置信区间 [CI]，0.03-0.22）、连枷胸（OR，0.1；95%CI，0.01-0.03）和格拉斯哥昏迷评分（GCS）小于 13（OR，0.28；95%CI，0.17-0.45），而速度和机制的整体评估单独是较差的预测因素（阳性似然比，0.92-1.4）。
结论
在巴黎地区，法国医生基于怀疑有重大创伤的患者的院前分诊系统显示出过度分诊率高，分诊不足率低。速度和机制的整体评估标准单独是重大创伤的较差预测因素。
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