钝性肝外伤处理中的变异性和美国外科医师学院创伤委员会验证状态对死亡率的影响。
Variability in management of blunt liver trauma and contribution of level of American College of Surgeons Committee on Trauma verification status on mortality.
机构信息
From the Department of Surgery (C.J.T.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (B.J.), University of Arizona, Tucson, Arizona; Department of Surgery (J.L.J., L.M.N., M.R.H.), University of Michigan, Ann Arbor; and Department of Surgery (G.A.I.), Spectrum Health Medical Group, Grand Rapids, Michigan.
出版信息
J Trauma Acute Care Surg. 2018 Feb;84(2):273-279. doi: 10.1097/TA.0000000000001743.
BACKGROUND
Patients who sustain blunt liver trauma and are treated at an American College of Surgeons Committee on Trauma-verified Level I trauma center have an overall lower risk of mortality compared with patients admitted to a level II trauma center. However, elements contributing to these differences are unknown. We hypothesize that practice variation exists between trauma centers in management of blunt liver injury. Our objective is to identify practice variations and their effect on clinical outcomes.
METHODS
Data from a statewide collaborative quality initiative for trauma were used. The data set contains information from 29 American College of Surgeons Committee on Trauma verified Levels I and II trauma centers from 2011 to 2016. Propensity score matching was used to create cohorts of patients treated at Levels I or II trauma centers. The 1:1 matched cohorts were used to compare in-hospital mortality, management strategy, complications, intensive care unit (ICU) and hospital length of stay, and failure to rescue.
RESULTS
Four hundred fifty-four patients with grade 3 or higher blunt liver injury were included. Patients treated at level II trauma centers had higher in-hospital mortality than those treated at Level I trauma centers (15.4% vs 8.8%, p = 0.03). Level II trauma centers used angiography less compared with Level I centers (p = 0.007) and admitted significantly fewer patients to the ICU (p = 0.002). The ICU status was associated with reduced mortality (7.2% vs 23.9%, p < 0.001). Despite a lower rate of overall complications, Level II trauma centers were more likely to fail in rescuing their patients (p = 0.045).
CONCLUSION
Admission with a high-grade liver injury to a Level II trauma center is associated with increased in-hospital mortality. Level II trauma centers were less likely to use angiography or admit high-grade liver injuries to the ICU. This variation in practice may lead to the inability to rescue critically ill patients. Future research should investigate contributors to underutilization of resources for patients with high-grade liver injuries.
LEVEL OF EVIDENCE
Care management, level IV.
背景
与收入到二级创伤中心的患者相比，在经过美国外科医师学会创伤委员会认证的一级创伤中心接受治疗的钝性肝外伤患者整体死亡率较低。然而，造成这些差异的因素尚不清楚。我们假设在钝性肝损伤的管理方面，创伤中心之间存在实践差异。我们的目标是确定实践差异及其对临床结果的影响。
方法
使用全州范围的创伤协作质量倡议的数据。该数据集包含了 2011 年至 2016 年期间来自 29 家经过美国外科医师学会创伤委员会认证的一级和二级创伤中心的信息。采用倾向评分匹配创建在一级或二级创伤中心接受治疗的患者队列。使用 1:1 匹配队列来比较院内死亡率、治疗策略、并发症、重症监护病房（ICU）和住院时间以及救援失败。
结果
共纳入 454 例 3 级或更高级别的钝性肝损伤患者。收入二级创伤中心的患者院内死亡率高于收入一级创伤中心的患者（15.4%比 8.8%，p = 0.03）。与一级中心相比，二级创伤中心较少使用血管造影（p = 0.007），且显著较少将患者收入 ICU（p = 0.002）。入住 ICU 与死亡率降低相关（7.2%比 23.9%，p < 0.001）。尽管整体并发症发生率较低，但二级创伤中心抢救患者的成功率较低（p = 0.045）。
结论
收入二级创伤中心的高分级肝损伤患者与院内死亡率增加相关。二级创伤中心较少使用血管造影或将高分级肝损伤收入 ICU。这种实践差异可能导致无法抢救重症患者。未来的研究应调查导致高分级肝损伤患者资源利用不足的因素。
证据水平
治疗管理，IV 级。
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