Division of Traumatology, Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA.
Division of Traumatology, Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA.
Surgery. 2021 Feb;169(2):460-469. doi: 10.1016/j.surg.2020.08.017. Epub 2020 Sep 19.
Pulmonary complications are the most common adverse event after injury and second greatest cause of failure to rescue (death after pulmonary complications). It is not known whether readily accessible trauma center data can be used to stratify center-level performance for various complications. Performance variation between trauma centers would allow sharing of best practices among otherwise similar hospitals. We hypothesized that high-, average-, and low-performing centers for pulmonary complication and failure to rescue could be identified and that hospital factors associated with success and failure could be discovered.
Pennsylvania state trauma registry data (2007-2015) were abstracted for pulmonary complications. Burns and age <17 were excluded. Multivariable logistic regression models were developed for pulmonary complication and failure to rescue, using demographics, comorbidities, and injuries/physiology. Expected event rates were compared with observed rates to identify outliers. Center-level variables associated with outcomes of interest were taken from the American Hospital Association Annual Survey Database and assessed for inclusion.
Included in the study were 283,121 patients (male [60%] blunt trauma [92%]). Of these patients, 3% (8,381 of 283,121) developed pulmonary complications (center-level range 0.18%-5.8%). The percentage of failure-to-rescue patients was 13.4% (1,120/8,381, center-level range 0.0%-22.6%). For pulmonary complications, 13 out of 27 centers were high performers (95% CI for O:E ratio <1) and 7 out of 27 were low (95% CI for an O:E ratio >1). For failure-to-rescue patients, 2 out of 27 centers were low performers and the remainder average. There was little concordance between performance for pulmonary complications and failure to rescue. Research programs, large non-teaching hospitals, those with advanced practice providers, and those with health maintenance organizations had reduced failure-to-rescue patients.
Factors associated with complications were distinct from those affecting failure to rescue and center-level success in reducing complications often did not translate into success in preventing death once they occurred. Our data demonstrate that high- and low-performing centers and the factors driving success or failure are identifiable. This work serves as a guide for comparing practices and improving outcomes with readily available data.
肺部并发症是受伤后最常见的不良事件，也是抢救失败（肺部并发症后死亡）的第二大原因。目前尚不清楚是否可以利用易于获得的创伤中心数据对各种并发症的中心表现进行分层。创伤中心之间的表现差异可以允许在其他方面相似的医院之间共享最佳实践。我们假设可以确定肺部并发症和抢救失败的高、中、低绩效中心，并且可以发现与成功和失败相关的医院因素。
从宾夕法尼亚州创伤登记处（2007-2015 年）中提取肺部并发症数据。排除烧伤和年龄<17 岁的患者。使用人口统计学、合并症和损伤/生理学，为肺部并发症和抢救失败建立多变量逻辑回归模型。将预期的事件发生率与观察到的发生率进行比较，以确定异常值。从美国医院协会年度调查数据库中获取与研究结果相关的中心变量，并评估其纳入情况。
本研究共纳入 283121 名患者（男性[60%]钝器伤[92%]）。这些患者中有 3%（8381 例/283121 例）发生肺部并发症（中心水平范围 0.18%-5.8%）。抢救失败患者的比例为 13.4%（1120 例/8381 例，中心水平范围 0.0%-22.6%）。对于肺部并发症，27 个中心中有 13 个为高绩效（95%置信区间<1），7 个为低绩效（95%置信区间>1）。对于抢救失败患者，27 个中心中有 2 个为低绩效，其余为中绩效。肺部并发症和抢救失败患者的表现之间几乎没有一致性。研究计划、大型非教学医院、拥有高级执业医师和拥有健康维护组织的医院抢救失败患者较少。
与并发症相关的因素与影响抢救失败的因素不同，在减少并发症方面的中心水平成功往往不能转化为预防一旦发生死亡的成功。我们的数据表明，可以确定高绩效、低绩效中心以及导致成功或失败的因素。这项工作为利用现成的数据比较实践和改善结果提供了指导。
