The effect of trauma center designation and trauma volume on outcome in specific severe injuries
The effect of trauma center designation and trauma volume on outcome in specific severe injuries
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DOI：
10.1097/01.sla.0000184169.73614.09
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发表时间：
2005-10-01
影响因子：
9
通讯作者：
Chan, L
中科院分区：
文献类型：
--
作者：
Demetriades, D;Martin, M;Chan, L
目的：本研究的目的是探讨美国外科学会（ACS）创伤中心名称和创伤量对特殊严重损伤患者预后的影响。背景：创伤中心被ACS根据资源、创伤量、教育和研究承诺划分为不同级别。创伤中心指定的标准是武断的，从未被验证过。方法：国家创伤数据库研究纳入了>4岁，损伤严重程度评分(ISS) >15的患者，入院时存活，至少有以下严重损伤之一：主动脉、腔静脉、髂血管、心脏、IV/V级肝损伤、四肢瘫痪或复杂骨盆骨折。结果（死亡率、重症监护病房住院时间和出院时严重残疾）在1级和11级创伤中心之间以及在相同级别名称但严重创伤量不同的中心之间进行比较（< 240 vs >= 240创伤住院ISS >每年15例）。结果根据年龄（< 65 >= 65）、性别、损伤机制、入院时低血压和ISS进行调整（25）。结果：12254例患者符合纳入标准。总体而言，一级中心的死亡率显著低于二级中心（25.3% vs 29.3%；调整优势比[OR]， 0.81； 95%可信区间[CI]， 0.71-0.94; P = 0.004），出院时严重残疾显著低于二级中心（20.3% vs 33.8%，调整优势比[OR]， 0.55; 95% Cl, 0.44-0.69, P < 0.001）。亚组分析显示，心血管损伤（N = 2004）和IV-V级肝损伤（N = 1415）在一级创伤中心的生存率明显高于二级创伤中心（调整后P分别为0.017和0.023）。总体而言，I级中心的功能结局明显更好（调整后P < 0.001）。亚组分析显示，I级中心治疗复杂骨盆骨折的功能预后明显较好（P < 0.001），其余亚组的预后也趋于较好。>5的创伤入院量（< 240例/年vs >= 240例/年）对I级或I级中心的预后没有影响。结论：对于与高死亡率和不良功能预后相关的特定损伤患者，一级创伤中心的预后优于低级创伤中心。重大创伤入院的数量不影响I级或II级中心的预后。这些发现可能对创伤系统的规划和根据认证水平计费服务具有重要意义。
Objective: The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries.Background: Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated.Methods: The National Trauma Data Bank study, which included patients > 14 years of age and had injury severity score (ISS) > 15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and 11 trauma centers and between centers within the same level designation but different volumes of severe trauma (< 240 vs >= 240 trauma admissions with ISS > 15 per year). The outcomes were adjusted for age (< 65 >= 65), gender, mechanism of injury, hypotension on admission, and ISS ( 25).Results: A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71-0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% Cl, 0.44-0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV-V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS > 15 (< 240 vs >= 240 cases per year) had no effect on outcome in either level I or I centers.Conclusions: Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.