James Melissa K, Lee Shi-Wen, Minneman Jennifer A, Moore Maureen D, Klein Taylor R, Robitsek R Jonathan, Barie Phillip S, Schubl Sebastian D
Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York.
Department of Emergency Medicine, Jamaica Hospital Medical Center, Jamaica, New York.
J Surg Res. 2017 Jun 1;213:6-15. doi: 10.1016/j.jss.2017.02.015. Epub 2017 Feb 24.
Trauma triage decisions can be influenced by both knowledge and experience. Consequently, there may be substantial variability in computed tomography (CT) scans desired by emergency medicine physicians, surgical chief residents, and attending trauma surgeons. We quantified this difference and studied the effects of each group's decisions on missed injuries, cost, and radiation exposure.
All blunt trauma activations at an urban level 1 trauma center were studied over a 6-mo period. Three months into the study, a pan-scan protocol was introduced. Prior to CT imaging, providers separately completed a survey that asked which CT scans were desired for each patient. Based on the completed surveys, hypothetical missed injuries, radiation exposure, and cost were determined.
The variability in the number of CT scans desired by each of the three providers and the resulting cost and radiation exposure were not statistically significant. Substantial variability was predominantly seen in the indications for the desired scans, with the difference between proportions ranging from 3.1%-68.7%. Agreement among the three providers was highest for head and c-spine scans (80%-100%) and lowest for maxillary face (57%-80%) and chest scans (52%-74%). Overall, the missed injury rate was similar for all the providers; chief residents missed significantly more major injuries than trauma attendings during the pan-scan period (P = 0.03).
Trauma training and level of training did not have a substantial effect on radiological decisions during the initial trauma assessment. This study sheds light on the growing uniformity among providers with regard to medical decision-making in the initial work-up of trauma.
创伤分诊决策可能受到知识和经验的影响。因此，急诊医学医生、外科住院总医师和创伤外科主治医生所要求的计算机断层扫描（CT）检查可能存在很大差异。我们对这种差异进行了量化，并研究了每组决策对漏诊损伤、成本和辐射暴露的影响。
对一家城市一级创伤中心6个月内所有钝性创伤激活病例进行研究。研究进行3个月后，引入了全扫描方案。在进行CT成像之前，医护人员分别完成一项调查，询问对每位患者需要进行哪些CT扫描。根据完成的调查，确定假设的漏诊损伤、辐射暴露和成本。
三位医护人员各自要求的CT扫描数量的差异以及由此产生的成本和辐射暴露在统计学上无显著意义。在所需扫描的指征方面主要存在很大差异，比例差异范围为3.1%-68.7%。三位医护人员对头颈部和颈椎扫描的一致性最高（80%-100%），对上颌面部（57%-80%）和胸部扫描的一致性最低（52%-74%）。总体而言，所有医护人员的漏诊损伤率相似；在全扫描期间，住院总医师漏诊的重伤明显多于创伤主治医生（P = 0.03）。
创伤培训和培训水平在初始创伤评估期间对放射学决策没有实质性影响。这项研究揭示了在创伤初步检查的医疗决策方面，医护人员之间的一致性正在不断提高。
