成熟创伤体系中高级生命支持转运的过筛和漏筛分析。
An analysis of overtriage and undertriage by advanced life support transport in a mature trauma system.
机构信息
From the Trauma Services (A.Y., E.H.B., M.E.M., T.M.V., K.E.B., F.B.R.), Penn Medicine Lancaster General Health, Lancaster, Pennslyvania; Robert Larner, MD College of Medicine at the University of Vermont (B.W.G.), Burlington, Vermont; and University of Texas Health Science Center at Tyler (A.D.C.), UT Health East Texas, Tyler, Texas.
出版信息
J Trauma Acute Care Surg. 2020 May;88(5):704-709. doi: 10.1097/TA.0000000000002602.
BACKGROUND
While issues regarding triage of severely injured trauma patients are well publicized, little information exists concerning the difference between triage rates for patients transported by advanced life support (ALS) and basic life support (BLS). We sought to analyze statewide trends in undertriage (UT) and overtriage (OT) to address this question, hypothesizing that there would be a difference between the UT and OT rates for ALS compared with BLS over a 13-year period.
METHODS
All patients submitted to Pennsylvania Trauma Outcomes Study database from 2003 to 2015 were analyzed. Undertriage was defined as not calling a trauma alert for patients with an Injury Severity Score (ISS) of 16 or greater. Overtriage was defined as calling a trauma alert for patients with an ISS of 9 or less. A logistic regression was used to assess mortality between triage groups in ALS and BLS. A multinomial logistic regression assessed the adjusted impact of ALS versus BLS transport on UT and OT versus normal triage while controlling for age, sex, Glasgow Coma Scale, systolic blood pressure (SBP), pulse, Shock Index and injury year.
RESULTS
A total of 462,830 patients met inclusion criteria, of which 115,825 had an ISS of 16 or greater and 257,855 had an ISS of 9 or less. Both ALS and BLS had significantly increased mortality when patients were undertriaged compared with the reference group. Multivariate analysis in the form of a multinomial logistic regression revealed that patients transported by ALS had a decreased adjusted rate of undertriage (relative risk ratio, 0.92; 95% confidence interval, 0.87-0.97; p = 0.003) and an increased adjusted rate of OT (relative risk ratio, 1.59; 95% confidence interval, 1.54-1.64; p < 0.001) compared with patients transported by BLS.
CONCLUSION
Compared with their BLS counterparts, while UT is significantly lower, OT is substantially higher in ALS-further increasing the high levels of resource (over)utilization in trauma patients. Undertriage in both ALS and BLS are associated with increased mortality rates. Additional education, especially in the BLS provider, on identifying the major trauma victim may be warranted based on the results of this study.
LEVEL OF EVIDENCE
Epidemiological, Level III.
背景
尽管严重创伤患者分诊问题已广为人知，但关于使用高级生命支持（ALS）和基本生命支持（BLS）转运的患者分诊率差异的信息却很少。我们试图通过分析全州范围内的低分诊（UT）和高分诊（OT）率来解决这个问题，并假设在 13 年的时间内，ALS 与 BLS 相比，UT 和 OT 率之间会存在差异。
方法
对 2003 年至 2015 年期间提交给宾夕法尼亚州创伤结局研究数据库的所有患者进行分析。低分诊定义为对于损伤严重度评分（ISS）为 16 或更高的患者未发出创伤警报。高分诊定义为对于 ISS 为 9 或更低的患者发出创伤警报。使用逻辑回归评估 ALS 和 BLS 分诊组之间的死亡率。多变量逻辑回归在控制年龄、性别、格拉斯哥昏迷评分、收缩压（SBP）、脉搏、休克指数和受伤年份的情况下，评估 ALS 与 BLS 转运对 UT 和 OT 与正常分诊的调整影响。
结果
共有 462830 名患者符合纳入标准，其中 115825 名患者的 ISS 为 16 或更高，257855 名患者的 ISS 为 9 或更低。与参考组相比，ALS 和 BLS 患者分诊不足时的死亡率均显著增加。多变量分析采用多项逻辑回归显示，与 BLS 转运的患者相比，ALS 转运的患者低分诊的调整率降低（相对风险比，0.92；95%置信区间，0.87-0.97；p = 0.003），高分诊的调整率增加（相对风险比，1.59；95%置信区间，1.54-1.64；p < 0.001）。
结论
与 BLS 相比，ALS 患者的 UT 明显降低，但 OT 显著升高，这进一步增加了创伤患者资源（过度）利用的高水平。ALS 和 BLS 中的低分诊和高分诊均与死亡率增加相关。根据这项研究的结果，可能需要对 ALS 和 BLS 中的医疗服务提供者进行更多的教育，特别是在识别重大创伤患者方面。
证据水平
流行病学，III 级。
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