Sampalis J S, Denis R, Fréchette P, Brown R, Fleiszer D, Mulder D
Montreal General Hospital, Quebec, Canada.
J Trauma. 1997 Aug;43(2):288-95; discussion 295-6. doi: 10.1097/00005373-199708000-00014.
The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals.
The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly.
The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001).
The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.
本研究的目的是比较直接转运至一级三级创伤中心的重伤患者与先转运至专业性较低的医院后再转诊的患者的治疗结果。
数据基于1993年4月1日至1995年12月31日期间在魁北克的三个三级创伤中心接受治疗的所有患者。有1608例患者（37%）被转诊，2756例患者（63%）直接转运。
患者的平均年龄约为45岁，超过60%为男性。主要损伤机制为跌倒和机动车碰撞。转诊组和直接转运组在年龄、性别和损伤机制方面相似。除头部或颈部损伤外，受伤的身体部位也相似（转诊组为56%；直接转运组为28%；p<0.0001）。平均损伤严重度评分是14分，院前指数评分平均为5.5分，修订创伤评分平均为7.5分。两组在这些损伤严重度指标方面相似。感兴趣的主要结局是死亡率，以总死亡率、急诊室死亡率和入院后死亡率来描述。研究的其他结局是住院时间和重症监护病房的治疗时长。与直接转运组相比，转诊患者的总死亡率风险增加（转诊组为8.9%；直接转运组为4.8%；优势比为1.96；95%置信区间（CI）=1.53 - 2.50），急诊室死亡率（转诊组为3.4%；直接转运组为1.2%；优势比为2.96；95% CI = 1.90 - 4.6），以及入院后死亡率（转诊组为5.5%；直接转运组为3.6%；优势比为1.57；95% CI = 1.17 - 2.11）。所有这些差异均具有统计学意义（p<0.003）。分层和多因素逻辑回归分析并未改变这些结果，也未能识别出转诊与死亡率风险降低相关的患者亚组。在对患者年龄、损伤严重度评分以及头部、颈部和四肢损伤情况进行校正后，转诊患者的住院时间和重症监护病房停留时间显著更长，平均住院时间（转诊组为16.0天；直接转运组为13.2天；p = 0.02）和平均重症监护病房停留时间（转诊组为2.0天；直接转运组为0.95天；p = 0.001）表明了这一点。
本研究结果表明，将重伤患者从现场直接转运至一级创伤中心可降低死亡率和发病率。需要进一步研究以评估农村创伤的转运方案。患者分诊的经济和成本效益考量也至关重要。
