我们自己的一个指标：创伤后救治失败。
A metric of our own: Failure to rescue after trauma.
作者信息
Holena Daniel N, Kaufman Elinore J, Delgado M Kit, Wiebe Douglas J, Carr Brendan G, Christie Jason D, Reilly Patrick M
机构信息
From the Division of Traumatology (D.N.H., P.M.R.), Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; The Penn Injury Science Center at the University of Pennsylvania (D.N.H., M.K.D., D.J.W., P.M.R.), Philadelphia, Pennsylvania; Department of Surgery (E.J.K.), Weill-Cornell School of Medicine, New York, New York; Department of Emergency Medicine (M.K.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics (D.J.W.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Emergency Medicine (B.G.C.), Jefferson University School of Medicine, Philadelphia, Pennsylvania.
出版信息
J Trauma Acute Care Surg. 2017 Oct;83(4):698-704. doi: 10.1097/TA.0000000000001591.
BACKGROUND
Failure to rescue (FTR) is defined as death after an adverse event. The original metric was derived in elective surgical populations and reclassifies deaths not preceded by recorded adverse events as FTR cases under the assumption these deaths resulted from missed adverse events. This approach lacks face validity in trauma because patients often die without adverse events as a direct result of injury. Another common approach simply excludes deaths without recorded adverse events, but this approach reduces the reliability of the FTR metric. We hypothesized that a hybrid metric excluding expected deaths but otherwise including patients without recorded adverse events in FTR analysis would improve face validity and reliability relative to existing methods.
METHODS
Using 3 years of single-state adult trauma registry data from 30 trauma centers, we constructed 3 FTR metrics: (1) excluding deaths not preceded by adverse events (FTR-E), (2) reclassifying deaths not preceded by adverse events (FTR-R), and (3) including deaths not preceded by adverse events in FTR analysis except those with predicted mortality or greater than 50% (FTR-T). Mortality, adverse event, and FTR rates were calculated under each method, and reliability was tested using Spearman correlation for split-sample center rankings.
RESULTS
A total of 89,780 patients were included (median age, 57 years [interquartile range, 26-73 years]; 85% were white; 59% were male; 92% had blunt mechanism of injury; median Injury Severity Score, 9 [interquartile range, 5-14]). The FTR rates varied by metric (FTR-E, 11.2%; FTR-R, 31.2%; FTR-T, 21.4%), as did the proportion of deaths preceded by adverse events (FTR-E, 28%; FTR-R, 100%; FTR-T, 60%). Spit-sample reliability was higher FTR-T than FTR-E (ρ = 0.59 vs. = 0.27, p < 0.001).
CONCLUSIONS
A trauma-specific FTR metric increases face validity and reliability relative to other FTR methods that may be used in trauma populations. Future trauma outcomes studies examining FTR rates should use a metric designed for this cohort.
LEVEL OF EVIDENCE
Retrospective cohort study, outcomes, level III.
背景
未能挽救（FTR）被定义为不良事件后的死亡。最初的指标是在择期手术人群中得出的，在假设这些死亡是由漏诊的不良事件导致的情况下，将没有记录到不良事件的死亡重新归类为FTR病例。这种方法在创伤领域缺乏表面效度，因为患者常常因受伤直接导致死亡而没有不良事件。另一种常见方法是简单地排除没有记录到不良事件的死亡，但这种方法降低了FTR指标的可靠性。我们假设，一种混合指标在FTR分析中排除预期死亡，但包括没有记录到不良事件的患者，相对于现有方法将提高表面效度和可靠性。
方法
利用来自30个创伤中心的3年单州成年创伤登记数据，我们构建了3种FTR指标：（1）排除没有不良事件的死亡（FTR-E），（2）将没有不良事件的死亡重新归类（FTR-R），以及（3）在FTR分析中包括没有不良事件的死亡，但预测死亡率大于或等于50%的除外（FTR-T）。在每种方法下计算死亡率、不良事件率和FTR率，并使用Spearman相关性对拆分样本中心排名进行可靠性测试。
结果
共纳入89780例患者（中位年龄57岁[四分位间距，26 - 73岁]；85%为白人；59%为男性；92%为钝性致伤机制；中位损伤严重程度评分9[四分位间距，5 - 14]）。FTR率因指标而异（FTR-E为11.2%；FTR-R为31.2%；FTR-T为21.4%），有不良事件的死亡比例也如此（FTR-E为28%；FTR-R为100%；FTR-T为60%）。拆分样本可靠性FTR-T高于FTR-E（ρ = 0.59对0.27，p < 0.001）。
结论
相对于可能用于创伤人群的其他FTR方法，一种针对创伤的FTR指标提高了表面效度和可靠性。未来研究FTR率的创伤结局研究应使用针对该队列设计的指标。
证据水平
回顾性队列研究，结局，III级。
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