Louras Nathan, Fortune John, Osler Turner, Hyman Neil
Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA.
Department of Surgery, University of Chicago Medicine, 5841 S Maryland Avenue, Chicago, IL 60637, USA.
Am J Surg. 2016 Jan;211(1):129-32. doi: 10.1016/j.amjsurg.2015.05.020. Epub 2015 Aug 5.
Care protocols can facilitate effective management of injured patients across a spectrum of providers. It is uncertain whether patient care is compromised when a full time trauma surgeon is not on call in the rural setting, where manpower may be a challenge.
A retrospective cohort study was performed at an academic medical center with a level I trauma center. Patients admitted to the trauma service from 2007 to 2012 were compared with respect to mortality, missed injuries, delay in diagnosis, and length of stay based on whether they were admitted to the trauma service when a full-time trauma surgeon was on call.
A total of 2,571 injured patients were admitted during the study period; 1,621 directly to the trauma service. Of those, 1,415 patients were initially seen by a trauma surgeon (group A) and 206 by a nontrauma surgeon (group B). Demographics were similar except that the trauma attending patients were somewhat older (44.7 vs 39.4 years, P = .002). There was no difference in the mean injury severity score (17.0 vs 16.0, P = .13) or Glasgow Coma Scale (12.7 vs 12.3, P = .7) between the 2 groups. There were 128 deaths; mortality rate in group A was 7.9% versus 7.7% for group B (P = .54). There was no difference in the incidence of delayed diagnosis or missed injuries (3.0 vs 3.4%, P = .8; .4 vs .9%, P = .27, respectively). The mean length of stay was shorter (7.9 vs 6.3, P = .016) in group B.
There was no increase in mortality, delayed diagnosis, or missed injuries when nontrauma surgeons took call. Systems of care and algorithms can be developed that provide staffing flexibility yet maintain safe and effective care to trauma patients in the rural setting.
护理协议有助于在各类医疗人员中对受伤患者进行有效管理。在农村地区，人力可能是一个挑战，当没有全职创伤外科医生随时待命时，患者护理是否会受到影响尚不确定。
在一家拥有一级创伤中心的学术医疗中心进行了一项回顾性队列研究。根据2007年至2012年期间入住创伤科的患者在全职创伤外科医生待命时是否入住创伤科，比较其死亡率、漏诊损伤、诊断延迟和住院时间。
研究期间共有2571名受伤患者入院；其中1621名直接入住创伤科。在这些患者中，1415名患者最初由创伤外科医生诊治（A组），206名由非创伤外科医生诊治（B组）。除了创伤主治医生诊治的患者年龄稍大（44.7岁对39.4岁，P = 0.002）外，两组的人口统计学特征相似。两组之间的平均损伤严重程度评分（17.0对16.0，P = 0.13）或格拉斯哥昏迷量表评分（12.7对12.3，P = 0.7）没有差异。共有128例死亡；A组的死亡率为7.9%，B组为7.7%（P = 0.54）。延迟诊断或漏诊损伤的发生率没有差异（分别为3.0%对3.4%，P = 0.8；0.4%对0.9%，P = 0.27）。B组的平均住院时间较短（7.9天对6.3天，P = 0.016）。
当非创伤外科医生值班时，死亡率、诊断延迟或漏诊损伤没有增加。可以制定护理系统和算法，在农村地区提供人员配置灵活性，同时为创伤患者维持安全有效的护理。
