Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, Japan.
Scand J Trauma Resusc Emerg Med. 2021 Jan 6;29(1):9. doi: 10.1186/s13049-020-00828-4.
Although the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.
This retrospective cohort study analyzed the data of Japan's nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.
A total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78-1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.
Physician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.
尽管先前的研究结果表明，由医生主导的院前创伤管理是有效的，但由于高质量研究的数量有限，其效果仍不确定。此外，由于一些研究中直升机运输缩短了院前时间，由医生主导的院前管理的优势可能被高估了。本研究旨在评估独立于院前时间的由医生主导的院前管理的效果。此外，还进行了亚组分析，以探索特别受益于由医生主导的院前管理的亚人群。
本回顾性队列研究分析了日本全国创伤登记处的数据。评估了 2009 年 4 月至 2019 年 3 月期间直接送往医院的严重钝性创伤患者，损伤严重程度评分（ISS）≥16 分。使用 1:4 倾向评分匹配分析，将主要院前医疗服务提供者（即医生或护理人员）的职业分为两组，比较两组患者的院内死亡率。使用潜在混杂因素（包括患者人口统计学特征、损伤机制、损伤现场生命体征、ISS 和从损伤到医院到达的总时间）计算倾向评分。通过评估医生主导的院前管理与患者特征之间的交互效应，探索特别受益于医生主导的院前管理的亚人群。
共有 30551 名患者（医生主导：2976 名，护理人员主导：27575 名）符合分析条件，其中生成并比较了 2690 对倾向评分匹配对（医生主导：2690 名，护理人员主导：10760 名）。与护理人员主导组相比，医生主导组的院内死亡率显著降低（院内死亡率：387 [14.4%] 和 1718 [16.0%]；优势比[95%置信区间]=0.88[0.78-1.00]，p=0.044）。年龄<65 岁、ISS≥25、骨盆和下肢损伤严重程度评分≥3 以及总院前时间<60 分钟的患者可能受益于医生主导的院前管理。
独立于院前时间，由医生主导的院前创伤管理与降低院内死亡率显著相关。探索性亚组分析的结果将有助于未来研究建立有效的医生团队派遣系统。
