Sharwood Lisa N, Dhaliwal Shelly, Ball Jonathon, Burns Brian, Flower Oliver, Joseph Anthony, Stanford Ralph, Middleton James
John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Clinical School, Sydney Medical School, University of Sydney, Reserve Road, St Leonards, NSW, 2065, Australia.
Department of Neurosurgery, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia.
BMC Emerg Med. 2018 Dec 20;18(1):57. doi: 10.1186/s12873-018-0207-0.
To describe pre-hospital, emergency department and acute care assessment and management practices of senior clinicians for patients with acute traumatic spinal cord injury (TSCI) across Australia; and to describe clinical practice variation.
We used a descriptive, cross-sectional study design to survey senior clinicians (greater than 10 years practice in this field) caring for patients with acute TSCI. The assessment, management and referral practices of prehospital, emergency department/trauma and surgical expert clinicians, across prehospital, early hospital care, diagnostic imaging and haemodynamic management were surveyed.
We invited 95 eligible senior clinicians; the response rate was 75%. Survey findings demonstrated overall lack of awareness or consistent use of evidence based published guidelines; many clinicians following 'locally written' or 'no particular' guideline. Practitioners were conflicted across multiple areas including patient assessment and diagnosis, treatment and transport decisions. Reported spinal immobilisation practices differed substantially, as did target setting for blood pressure; the majority of clinicians actively monitored risk of respiratory deterioration. Specialist care consult and specialist service bed availability was reported as problematic by more than one third of clinicians.
Unwarranted clinical practice variation is known to contribute to different health outcomes for patients with similar etiologies. Clinical practice guidelines offer evidence based, best practice standards, however are only effective if adopted throughout the healthcare system. Wide variability in acute care practices, pathways and timing to specialist centres for TSCI was evidenced by this survey despite seniority among clinicians. This devastating injury requires prompt, consistent, evidence based care from the moment of first responder. Improved outcomes for patients with TSCI would be more likely with standardised care across pre-hospital, emergency and acute care phases of care.
描述澳大利亚资深临床医生对急性创伤性脊髓损伤（TSCI）患者的院前、急诊科及急性护理评估与管理实践；并描述临床实践差异。
我们采用描述性横断面研究设计，对护理急性TSCI患者的资深临床医生（该领域从业超过10年）进行调查。调查了院前、急诊科/创伤及外科专家临床医生在院前、早期医院护理、诊断性影像学检查及血流动力学管理方面的评估、管理及转诊实践。
我们邀请了95名符合条件的资深临床医生；回复率为75%。调查结果表明，总体上缺乏对已发表的循证指南的认识或一致应用；许多临床医生遵循“本地编写”或“无特定”指南。从业者在多个领域存在分歧，包括患者评估与诊断、治疗及转运决策。报告的脊柱固定实践差异很大，血压目标设定也是如此；大多数临床医生积极监测呼吸恶化风险。超过三分之一的临床医生报告称，专科护理咨询及专科服务床位可用性存在问题。
已知不必要的临床实践差异会导致病因相似的患者出现不同的健康结局。临床实践指南提供了循证的最佳实践标准，但只有在整个医疗系统中采用才有效。尽管临床医生资历较深，但本次调查证明，TSCI患者在急性护理实践、转诊途径及到达专科中心的时间方面存在很大差异。这种严重损伤从第一响应者介入之时起就需要迅速、一致、循证的护理。在院前、急诊及急性护理阶段采用标准化护理，TSCI患者更有可能获得更好的结局。
