Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services.
Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services.
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DOI：
10.1001/jamasurg.2016.3329
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发表时间：
2017-01-01
期刊：
影响因子：
16.9
通讯作者：
Hansen M
中科院分区：
文献类型：
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作者：
Newgard CD;Fu R;Bulger E;Hedges JR;Mann NC;Wright DA;Lehrfeld DP;Shields C;Hoskins G;Warden C;Wittwer L;Cook JN;Verkest M;Conway W;Somerville S;Hansen M
尽管美国农村人口众多，但农村和城市地区在创伤后的过程和结果方面存在潜在差异。描述和评估农村与城市的护理过程，受伤的严重程度，并在受伤的病人提供9 - 1 - 1紧急医疗服务（EMS）的死亡率。这是对2011年1月1日至12月31日入组的前瞻性队列进行的预先计划的次要分析，并随访至住院。该研究包括44个EMS机构运送到俄勒冈州和华盛顿的2个农村县和5个城市县的28家医院。一个以人口为基础的，连续样本67047受伤的儿童和成人EMS（1971农村和65076城市）服务。在EMS运送的53，487名患者中，创建了17，633名患者（1，438名农村患者和16，195名城市患者）的分层概率样本来跟踪医院结局（78.9%进行了住院随访）。数据分析于2015年6月12日至2016年5月20日进行。农村在县一级被定义为60分钟或更长的车程接近最近的一级或二级创伤中心和/或农村指定的医疗保险和医疗补助服务中心救护车费用表按邮政编码。死亡率（院外和院内）、早期关键资源需求和转移率。在EMS运送的53 487名受伤患者中（概率样本中有17 633名患者），27 535名为女性（51.5%）;平均（SD）年龄为51.6（26.1）岁。农村与城市的现场分诊识别需要早期关键资源的患者的敏感性分别为65.2%和80.5%，只有29.4%的农村患者需要关键资源最初被运送到主要的创伤中心，而城市患者的88.7%。在考虑转移后，39.8%的需要关键资源的农村患者在主要创伤中心接受治疗，而城市患者的比例为88.7%。农村和城市地区的总体死亡率没有差异（1.44% vs 0.89%; P = 0.09）;然而，89.6%的农村死亡发生在24小时内，而城市死亡为64%。农村地区的转移率较高（3.2%对2.7%），转移距离较长（中位数，97.4公里;四分位距[IQR]，51.7 - 394.5公里;范围，47.8 - 398.6公里对22.5公里; IQR，11.6 - 24.6公里;范围，3.5 - 97.4公里）。大多数在农村地区受伤的高危创伤患者在主要创伤中心外得到护理，大多数农村创伤死亡发生较早，尽管各地区的总体死亡率没有差异。农村地区受伤病人有机会更及时地获得重大创伤护理。
Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma. To describe and evaluate rural vs urban processes of care, injury severity, and mortality among injured patients served by 9-1-1 emergency medical services (EMS). This was a preplanned secondary analysis of a prospective cohort enrolled from January 1 through December 31, 2011, and followed up through hospitalization. The study included 44 EMS agencies transporting to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. A population-based, consecutive sample of 67047 injured children and adults served by EMS (1971 rural and 65 076 urban) was enrolled. Among the 53 487 patients transported by EMS, a stratified probability sample of 17 633 patients (1438 rural and 16 195 urban) was created to track hospital outcomes (78.9% with in-hospital follow-up). Data analysis was performed from June 12, 2015, to May 20, 2016. Rural was defined at the county level by 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the Centers for Medicare & Medicaid Services ambulance fee schedule by zip code. Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates. Of the 53 487 injured patients transported by EMS (17 633 patients in the probability sample), 27 535 were women (51.5%); mean (SD) age was 51.6 (26.1) years. Rural vs urban sensitivity of field triage for identifying patients requiring early critical resources was 65.2% vs 80.5%, and only 29.4% of rural patients needing critical resources were initially transported to major trauma centers vs 88.7% of urban patients. After accounting for transfers, 39.8% of rural patients requiring critical resources were cared for in major trauma centers vs 88.7% of urban patients. Overall mortality did not differ between rural and urban regions (1.44% vs 0.89%; P = .09); however, 89.6% of rural deaths occurred within 24 hours compared with 64% of urban deaths. Rural regions had higher transfer rates (3.2% vs 2.7%) and longer transfer distances (median, 97.4 km; interquartile range [IQR], 51.7-394.5 km; range, 47.8-398.6 km vs 22.5 km; IQR, 11.6-24.6 km; range, 3.5-97.4 km). Most high-risk trauma patients injured in rural areas were cared for outside of major trauma centers and most rural trauma deaths occurred early, although overall mortality did not differ between regions. There are opportunities for improved timeliness and access to major trauma care among patients injured in rural regions.