Lale Allison, Krajewski Allison, Friedman Lee S
Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago.
JAMA Surg. 2017 May 1;152(5):467-474. doi: 10.1001/jamasurg.2016.5049.
National anatomic triage criteria prescribe specific transport rules for injured patients. However, there is limited information about patients with firearm-related injuries undertriaged to nondesignated facilities (ie, hospitals without specialized trauma teams or units), including what clinical outcomes are achieved and how many are transferred to a higher level of care. Without these data, it is difficult to make informed regional or national policy decisions about triage practices. Undertriage of firearm-related injuries is a good model for evaluating the undertriage of patients with trauma because the anatomic triage criteria for patients with firearm-related injuries are simple.
To evaluate the prevalence, spatial distribution, and clinical outcomes of undertriage of firearm-related injuries.
DESIGN, SETTING, AND PARTICIPANTS: This study is a retrospective analysis of firearm-related injuries in residents of Cook County, Illinois, from January 1, 2009, to December 31, 2013. Outpatient and inpatient hospital databases were used. Participants included patients with International Classification of Diseases, Ninth Revision, Clinical Modification firearm-related cause-of-injury codes. Data were collected all at once in August 2014. Data analysis took place from March 12, 2015, to February 1, 2016.
Undertriaged cases were defined as patients who met the national anatomic triage criteria for transfer to higher-level trauma center care. Spatial distribution, injury severity, and clinical outcomes, including death, were analyzed.
Of the 9886 patients included in this analysis, 8955 (90.6%) were male, 7474 (75.6%) were African American, and 5376 (54.4%) were aged 15 to 24 years.In Cook County, Illinois, where there are 19 trauma centers, 2842 of 9886 (28.7%) firearm-related injuries were initially treated in nondesignated facilities. Among the 4934 cases with firearm-related injury who met the anatomic triage criteria, 884 (17.9%) received initial treatment at a nondesignated facility and only 92 (10.4%) were transferred to a designated trauma center. Significant spatial clustering was identified on the west side of Chicago and in the southern parts of Chicago and Cook County. In the multivariable models, patients treated in nondesignated facilities were less likely to die than were patients treated in designated trauma centers.
Undertriage of firearm-related injuries was much more prevalent than expected. Although the likelihood of dying during hospitalization was greater among patients treated in designated trauma centers, these patients were substantially in worse condition across all measures of injury severity. A smaller proportion of patients treated in designated trauma centers died during the first 24 hours of hospitalization. This study highlights the need for better regional coordination, especially with interhospital transfers, as well as the importance of assessing the distribution of emergency medical services resources to make the trauma care system more effective and equitable.
国家解剖分诊标准规定了受伤患者的特定转运规则。然而，关于被分诊至非指定医疗机构（即没有专业创伤团队或科室的医院）的火器伤患者的信息有限，包括其临床结局以及被转至更高护理级别的患者数量。没有这些数据，就难以做出明智的区域或国家分诊实践政策决策。火器伤的分诊不足是评估创伤患者分诊不足的一个良好模型，因为火器伤患者的解剖分诊标准很简单。
评估火器伤分诊不足的患病率、空间分布及临床结局。
设计、设置与参与者：本研究是对2009年1月1日至2013年12月31日伊利诺伊州库克县居民火器伤的回顾性分析。使用了门诊和住院医院数据库。参与者包括国际疾病分类第九版临床修订本中与火器相关的损伤原因编码的患者。数据于2014年8月一次性收集。数据分析于2015年3月12日至2016年2月1日进行。
分诊不足的病例定义为符合转至更高级别创伤中心护理的国家解剖分诊标准的患者。分析了空间分布、损伤严重程度及临床结局，包括死亡情况。
本分析纳入的9886例患者中，8955例（90.6%）为男性，7474例（75.6%）为非裔美国人，5376例（54.4%）年龄在15至24岁之间。在伊利诺伊州库克县，有19个创伤中心，9886例火器伤中有2842例（28.7%）最初在非指定医疗机构接受治疗。在符合解剖分诊标准的4934例火器伤病例中，884例（17.9%）在非指定医疗机构接受了初始治疗，只有92例（10.4%）被转至指定创伤中心。在芝加哥西侧以及芝加哥和库克县南部发现了显著的空间聚集现象。在多变量模型中，在非指定医疗机构接受治疗的患者死亡可能性低于在指定创伤中心接受治疗的患者。
火器伤的分诊不足比预期更为普遍。尽管在指定创伤中心接受治疗的患者住院期间死亡可能性更大，但在所有损伤严重程度衡量指标方面，这些患者的病情要严重得多。在指定创伤中心接受治疗的患者中，在住院的最初24小时内死亡的比例较小。本研究强调了加强区域协调的必要性，尤其是医院间转运方面，以及评估急诊医疗服务资源分布以使创伤护理系统更有效和公平的重要性。
