Ruchholtz S, Zintl B, Nast-Kolb D, Waydhas C, Schwender D, Pfeifer K J, Schweiberer L
Chirurgische Klinik und Poliklinik Klinikum Innenstadt, Ludwig-Maximilians-Universität München.
Unfallchirurg. 1997 Nov;100(11):859-66. doi: 10.1007/s001130050205.
To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988-12/1993 (A; n = 126) and 1/1994-6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97% vs. 92% of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5% vs. 24%; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (7) period of 79 min vs. 98 min until emergency operation in shock; (8) duration of 95 min vs. 124 min until trepanation, and (9) operation rate within 24 h after admission to ICU in 3% vs. 12%. The lethality rates of each collective were assessed after subdivision in three groups (I-III) with middle (ISS: 18-24), high (ISS: 25-49) and extreme (ISS: 50-75) injury severity. In all groups of both collectives ISS values, age, initial loss of consciousness (GCS) and shock were comparable (except the higher injury severity of collective B in group I). In all groups a reduction of lethality could be shown for collective B: Group I, 0% vs. 20% (P < 0.05); group II, 8% vs. 24% (P < 0.05); and group III, 40% vs. 71%, not significant because of the small group in B (n = 5). The implementation of therapeutic management guidelines led to an improvement of both treatment processes and outcome. In order to regularly reassess validity and practicability of such guidelines as well as further enhance therapeutic quality, a continuous evaluation programme representing a quality management system should be inaugurated.
为提高多发伤（钝器伤）患者的治疗质量，1994年我们诊所实施了急性临床管理指南（创伤治疗流程）。分析了这些指南的影响，比较了两个前瞻性记录的多发伤患者群体，分别为1988年4月至1993年12月（A组；n = 126）和1994年1月至1996年6月（B组；n = 74）。使用九个明确界定的参数评估早期临床创伤管理的治疗过程。在实施治疗流程后（B组），所有参数均有改善：（1）97%的患者完成了放射学和超声基本诊断，而A组为92%；（2）重度颅脑损伤（格拉斯哥昏迷评分<10）后至进行头颅CT检查的时间间隔为38分钟，A组为55分钟；（3）损伤延迟诊断率降至5%，A组为24%；（4）至插管的时间为16分钟，A组为20分钟；（5）至胸腔引流的时间为23分钟至30分钟；（6）休克时至输血的时间为18分钟，A组为32分钟；（7）休克时至急诊手术的时间为79分钟，A组为98分钟；（8）至开颅手术的时间为95分钟，A组为124分钟；（9）入住重症监护病房后24小时内的手术率为3%，A组为12%。将每个群体的致死率按损伤严重程度分为三组（I - III组）进行评估，中度（损伤严重度评分：18 - 24）、高度（损伤严重度评分：25 - 49）和极重度（损伤严重度评分：50 - 75）。两个群体的所有组在损伤严重度评分、年龄、初始意识丧失（格拉斯哥昏迷评分）和休克情况方面均具有可比性（I组中B组损伤严重度较高除外）。在所有组中，B组的致死率均有所降低：I组，0%对20%（P < 0.05）；II组，8%对24%（P < 0.05）；III组，40%对71%，因B组该组样本量小（n = 5）无统计学意义。治疗管理指南的实施使治疗过程和结果均得到改善。为定期重新评估此类指南的有效性和实用性，并进一步提高治疗质量，应启动一个代表质量管理体系的持续评估项目。
