Burstein J L, Henry M C, Alicandro J M, McFadden K, Thode H C, Hollander J E
Department of Emergency Medicine, State University of New York at Stony Brook, University Medical Center 11794-7400, USA.
Acad Emerg Med. 1996 Nov;3(11):1011-5. doi: 10.1111/j.1553-2712.1996.tb03344.x.
To determine whether out-of-hospital care charts selectively report trauma triage criteria, and the impact of such documentation on triage guideline development.
A special structured data instrument that requested the presence or absence of the American College of Surgeons (ACS) trauma triage criteria was completed by emergency medical services (EMS) personnel transporting victims of motor vehicle crashes. The standard written EMS report forms for a subset of 199 patients with at least 1 ACS trauma triage mechanism criterion were reviewed by the investigators. Outcome data were obtained from medical record review. The structured data instrument and the standard EMS report were compared for concordance. The impact of method of data collection on the ability of the ACS criteria to predict patient outcome was determined.
EMS reports and structured data instruments similarly noted the presence of anatomic, physiologic, and "other" trauma triage criteria (p > 0.07 for all individual comparisons). Most mechanism-of-injury criteria noted on the data instrument (pedestrian struck > 20 mph; crash speed > 20 mph; vehicle deformity; compartment intrusion; rollover; and ejection) were infrequently documented on the standard EMS report (median 28.5% noted, range 0-100%). Patients who had mechanism criteria noted on the EMS report were more likely to be admitted to the hospital (44% vs 13%; p = 0.006), to require major operative procedures (10% vs 0%; p = 0.005), and to have prolonged lengths of stay (26% vs 9%; p = 0.02) and injury severity scores > or = 16 (15% vs 3%; p = 0.03) than were patients who had mechanism criteria documented only on the structured data instrument.
In the authors' EMS system, standard EMS report documentation underreports ACS trauma triage mechanism criteria. This underreporting appears to bias outcome analysis in the direction of a worse outcome and more resource utilization. Reporting of mechanism-of-injury criteria improves with use of a structured data instrument.
确定院外护理记录是否选择性地报告创伤分诊标准，以及此类记录对分诊指南制定的影响。
由运送机动车碰撞事故受害者的紧急医疗服务（EMS）人员填写一份特殊的结构化数据工具，该工具要求记录美国外科医师学会（ACS）创伤分诊标准的存在与否。研究人员审查了199例至少有1项ACS创伤分诊机制标准的患者子集的标准书面EMS报告表。通过病历审查获取结果数据。比较结构化数据工具和标准EMS报告的一致性。确定数据收集方法对ACS标准预测患者结局能力的影响。
EMS报告和结构化数据工具同样记录了解剖学、生理学和“其他”创伤分诊标准（所有个体比较的p>0.07）。数据工具中记录的大多数损伤机制标准（行人被时速>20英里撞击；碰撞速度>20英里；车辆变形；车厢侵入；翻车；和弹射）在标准EMS报告中很少记录（记录的中位数为28.5%，范围为0-100%）。在EMS报告中记录了机制标准的患者比仅在结构化数据工具中记录了机制标准的患者更有可能入院（44%对13%；p=0.006）、需要进行大手术（10%对0%；p=0.005）、住院时间延长（26%对9%；p=0.02）以及损伤严重程度评分≥16（15%对3%；p=0.03）。
在作者所在的EMS系统中，标准EMS报告记录未充分报告ACS创伤分诊机制标准。这种未充分报告似乎使结局分析朝着更差的结局和更多资源利用的方向产生偏差。使用结构化数据工具可改善损伤机制标准的报告情况。
