Fom the Department of Surgery (C.J.T.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (W.E.V.K.), Mercy Health, Grand Rapids, Michigan; Department of Surgery (J.N.M., M.J.D., M.R.H.), University of Michigan, Ann Arbor, Michigan.
J Trauma Acute Care Surg. 2018 Feb;84(2):287-294. doi: 10.1097/TA.0000000000001745.
The appropriate triage of acutely injured patients within a trauma system is associated with improved rates of mortality and optimal resource utilization. The American College of Surgeons Committee on Trauma (ACS-COT) put forward six minimum criteria (ACS-6) for full trauma team activation (TTA). We hypothesized that ACS-COT-verified trauma center compliance with these criteria is associated with low undertriage rates and improved overall mortality.
Data from a state-wide collaborative quality initiative was used. We used data collected from 2014 through 2016 at 29 ACS verified Level I and II trauma centers. Inclusion criteria are: adult patients (≥16 years) and Injury Severity Score of 5 or less. Quantitative data existed to analyze four of the ACS-6 criteria (emergency department systolic blood pressure ≤ 90 mm Hg, respiratory compromise/intubation, central gunshot wound, and Glasgow Coma Scale score < 9). Patients were considered to be undertriaged if they had major trauma (Injury Severity Score > 15) and did not receive a full TTA.
51,792 patients were included in the study. Compliance with ACS-6 minimum criteria for full TTA varied from 51% to 82%. The presence of any ACS-6 criteria was associated with a high intervention rate and significant risk of mortality (odds ratio, 16.7; 95% confidence interval, 15.2-18.3; p < 0.001). Of the 1,004 deaths that were not a full activation, 433 (43%) were classified as undertriaged, and 301 (30%) had at least one ACS-6 criterion present. Undertriaged patients with any ACS-6 criteria were more likely to die than those who were not undertriaged (30% vs. 21%, p = 0.001). Glasgow Coma Scale score less than 9 and need for emergent intubation were the ACS-6 criteria most frequently associated with undertriage mortality.
Compliance with ACS-COT minimum criteria for full TTA remains suboptimal and undertriage is associated with increased mortality. These data suggest that the most efficient quality improvement measure around triage should be ensuring compliance with the ACS-6 criteria. This study suggests that practice pattern modification to more strictly adhere to the minimum ACS-COT criteria for full TTA will save lives.
Care management, level III.
在创伤体系内对急性损伤患者进行适当分诊与死亡率的降低和最佳资源利用相关。美国外科医师学院创伤委员会（ACS-COT）提出了充分激活创伤团队（TTA）的六个最低标准（ACS-6）。我们假设符合这些标准的 ACS-COT 验证创伤中心的分诊符合率低，整体死亡率得到改善。
使用全州协作质量倡议的数据。我们使用了 2014 年至 2016 年在 29 个 ACS 验证的一级和二级创伤中心收集的数据。纳入标准为：成人患者（≥16 岁）和损伤严重程度评分 5 分或以下。存在定量数据来分析 ACS-6 标准中的四个标准（急诊室收缩压≤90mmHg，呼吸窘迫/插管，中心枪伤和格拉斯哥昏迷评分<9）。如果患者有重大创伤（损伤严重程度评分>15）且未接受充分的 TTA，则认为分诊不足。
研究纳入 51792 例患者。符合 ACS-6 充分 TTA 的最低标准的比例从 51%到 82%不等。任何 ACS-6 标准的存在均与高干预率和显著的死亡率相关（优势比，16.7；95%置信区间，15.2-18.3；p<0.001）。在 1004 例非充分激活的死亡中，433 例（43%）被归类为分诊不足，301 例（30%）存在至少一个 ACS-6 标准。存在任何 ACS-6 标准的分诊不足患者比未分诊不足的患者更有可能死亡（30%比 21%，p=0.001）。格拉斯哥昏迷评分<9 和需要紧急插管是与分诊不足死亡率最相关的 ACS-6 标准。
符合 ACS-COT 充分 TTA 的最低标准的情况仍不理想，分诊不足与死亡率增加相关。这些数据表明，围绕分诊的最有效的质量改进措施应该是确保符合 ACS-6 标准。本研究表明，修改实践模式以更严格地遵守充分的 ACS-COT 最低标准进行分诊将拯救生命。
管理护理，III 级。
