Brice Jane H, Shofer Frances S, Cowden Christopher, Lerner E Brooke, Psioda Matthew, Arasaratanam Meredith, Mann N Clay, Fernandez Antonio R, Waller Anna, Moss Chailee, Mian Michael
Prehosp Emerg Care. 2017 Sep-Oct;21(5):591-604. doi: 10.1080/10903127.2017.1308606. Epub 2017 Apr 19.
OBJECTIVE: Timely triage and appropriate destination decision making for injured patients are central challenges faced by emergency medical services (EMS) systems. In 2010, North Carolina (NC) adopted a statewide Trauma Triage and Destination Plan (TTDP) based on the CDC's Field Triage Guidelines to better address these challenges. We sought to characterize the implementation of these guidelines by quantifying their effect on multiple metrics of patient care. METHODS: We employed a retrospective pre-post study design utilizing a statewide EMS medical record database. We assessed several metrics of patient care-including changes in destination choice, appropriateness of EMS destination, transit time to first hospital, transit time to definitive care, and others-in a six-month period in the year before and after the implementation of the guidelines. RESULTS: We evaluated a total of 190,307 EMS encounters pre- (n = 93,927) and post-implementation (n = 96,380). Among all patients, there was not a significant difference in the percentage transported to a community hospital or Level I, II, or III trauma center as their first destination. Among those patients meeting TTDP guidelines for transport to a trauma center, the number transported to a Level I or II trauma center decreased 1.0% from 30.6% (n = 2,911) to 29.6% (n = 2,954) (95% CI: -0.2%, 2.2%). Those transported to a Level I trauma center decreased 0.4% from 21.2% to 20.8% in the post-period (95% CI: -0.7%, 1.5%). There were also no significant changes in EMS scene times (14.0 pre-, 14.1 post-) and transport times (12.9 pre-, 13.0 post-). While scene distance from a Level I trauma center showed a decreased likelihood of transport to that center, there was an overall post-implementation increase of 2.5% from 18.0% to 20.5% (95% CI: -3.6%, -1.3%) in transport to a Level I trauma center among patients meeting anatomic criteria across all distance ranges. CONCLUSIONS: We found that implementation of region-specific destination plans based on the Field Triage Guidelines had little effect on selected hospital destination, scene times, transport times, and other metrics of EMS decision making and effectiveness. We suspect this is due to delays in information dissemination and adoption by field providers.
目的：为受伤患者进行及时分诊并做出合适的目的地决策，是紧急医疗服务（EMS）系统面临的核心挑战。2010年，北卡罗来纳州（NC）基于美国疾病控制与预防中心（CDC）的现场分诊指南，采用了一项全州范围的创伤分诊与目的地计划（TTDP），以更好地应对这些挑战。我们试图通过量化其对患者护理多个指标的影响，来描述这些指南的实施情况。 方法：我们采用回顾性前后对照研究设计，利用全州范围的EMS医疗记录数据库。我们评估了患者护理的几个指标，包括目的地选择的变化、EMS目的地的适宜性、到第一家医院的转运时间、到确定性治疗的转运时间等，分别在指南实施前后的六个月内进行评估。 结果：我们总共评估了实施前（n = 93,927）和实施后（n = 96,380）的190,307次EMS出诊。在所有患者中，作为第一目的地被转运到社区医院或一级、二级或三级创伤中心的百分比没有显著差异。在那些符合TTDP指南转运至创伤中心的患者中，被转运至一级或二级创伤中心的人数从30.6%（n = 2,911）降至29.6%（n = 2,954），下降了1.0%（95%置信区间：-0.2%，2.2%）。在后一时期，被转运至一级创伤中心的人数从21.2%降至20.8%，下降了0.4%（95%置信区间：-0.7%，1.5%）。EMS现场时间（实施前14.0，实施后14.1）和转运时间（实施前12.9，实施后13.0）也没有显著变化。虽然离一级创伤中心的现场距离显示被转运至该中心的可能性降低，但在所有距离范围内符合解剖学标准的患者中，实施后转运至一级创伤中心的总体比例从18.0%增加到20.5%，增加了2.5%（95%置信区间：-3.6%，-1.3%）。 结论：我们发现，基于现场分诊指南实施特定区域的目的地计划，对选定的医院目的地、现场时间、转运时间以及EMS决策和有效性的其他指标影响甚微。我们怀疑这是由于现场工作人员信息传播和采用的延迟所致。
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