Department of Anesthesia and Critical Care, Hôpital Beaujon, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique-Hôpitaux de Paris, Clichy, France.
Trauma System of the Northern French Alps Emergency Network (Trauma System du Réseau Nord Alpin des Urgences [TRENAU]), Hospital Annecy Genevois, Annecy, France.
JAMA Surg. 2019 Dec 1;154(12):1117-1124. doi: 10.1001/jamasurg.2019.3475.
The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain.
To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018.
The association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality.
A total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 (14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score ≥3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]).
In this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.
在配备医生的创伤系统中，总院前时间与死亡率之间的关系仍不确定。
描述法国配备医生的创伤院前系统中总院前时间与院内死亡率之间的关系，并假设总院前时间与死亡率增加有关。
设计、地点和参与者：这项队列研究于 2009 年 1 月至 2016 年 12 月进行。本研究的数据来自法国的 2 个不同的区域创伤登记处（1 个城市和 1 个农村），均设有配备医生的紧急医疗服务。在此期间，连续纳入在研究期间被收入任何一个区域创伤转诊中心的成年创伤患者。数据分析于 2018 年 3 月至 2018 年 9 月进行。
使用多变量模型评估死亡与院前时间之间的关系，并进行混杂因素调整。总院前时间是主要暴露变量，记录为从医生领导的院前护理团队到达现场到到达医院的时间。主要观察结果是所有原因的院内死亡率。
共纳入 10216 例患者（平均[SD]年龄，41[18]岁；7937 例男性[78.3%]），主要为非穿透性损伤（9265 例[91.5%]），平均损伤严重度评分（Injury Severity Score）为 17（14）分。患者中，6737 例（66.5%）至少有 1 个身体部位的损伤严重度评分（Abbreviated Injury Scale）达到 3 或更高。共有 1259 例（12.4%）患者出现休克（收缩压＜90mmHg），2724 例（26.9%）患者出现严重头部损伤（损伤严重度评分≥3 分）。在未调整的分析中，院前时间（每 30 分钟分类）的增加与院内死亡风险的显著且持续增加有关。院前时间每增加 10 分钟，死亡的几率增加 9%（优势比，1.09[95%CI，1.07-1.11]），调整混杂因素后增加 4%（优势比，1.04[95%CI，1.01-1.07]）。
在这项研究中，在配备医生的紧急医疗系统中，创伤患者的总院前时间增加与院内全因死亡率增加相关，在调整病例复杂性后更是如此。院前时间是类似于生理目标的管理目标。这些发现表明需要进一步简化院前创伤护理，并需要定义最佳干预与时间的比值。
