Prospective Validation and Cost Analysis of the National Guidelines for Field Tri

描述（由申请人提供）： 建议方法：院外创伤分诊是创伤系统的重要组成部分，也是将重伤患者集中在主要创伤中心的主要机制，但分诊指南从未得到严格验证或进行正式的成本分析。在这个项目中，我们将使用一个前瞻性的，以人群为基础的，医院外的儿童，成人和老年人受伤队列，以检查现场分诊指南的准确性和成本影响，以及改进分诊算法的机会。重要性：迫切需要数据驱动的解决方案来提高创伤系统的效率，降低成本，保护宝贵的资源，同时仍然最大限度地提高伤害结果。这项研究的结果可能会有实质性的影响，提高成本效益的严重受伤的病人的区域化。目的：该应用程序的总体目标是在广泛的、有代表性的损伤人群中生成决策方案准确性（灵敏度和特异性）的无偏年龄特异性估计值，并密切评估现场分诊的成本影响。我们的假设是，分诊指南有较高的下和过度分诊率比以前认识到的，分诊是严重影响EMS供应商的判断，并有显着的成本影响与错误的分诊。该提案有三个具体目标：具体目标1。使用广泛的院外伤害队列，Profitness验证了2个城市/郊区站点和1个农村站点中儿童、成人和老年人的现场分诊决策方案。具体目标2。评估个体分诊标准（包括EMS提供者判断）的效用，并在预先指定的儿童、成人和老年人年龄层内重新推导现场创伤分诊指南。具体目标3。对决策方案进行正式的成本分析，包括医院类型和分诊标准的差异，过度和不足的分诊，以及现场分诊不同策略的成本效益。研究设计：基于人群、观察性、连续患者前瞻性队列。背景：本研究将在3个研究中心进行：波特兰，OR/温哥华（4个县）;华盛顿州金县;和约瑟芬县，OR（农村研究中心）。将包括43个EMS机构和19家急性护理医院（3家一级医院、1家二级医院、3家三级医院、4家四级医院和8家非指定社区医院）。参会人员：该研究将包括所有有9-1-1反应和EMS提供者对“创伤”的主要印象的人，无论是否符合分流指南、运输目的地或结果。EMS队列将包括58，800名受伤患者，其中10，877名（主要样本）被抽样用于医院结局。结果测量：主要结果将是“严重”损伤（最高简明损伤量表评分3分）。次要结局将是严重损伤或创伤资源使用的复合指标（大手术干预、介入放射学、ICU住院时间> 2天、输血、延长通气或住院死亡率）。成本将使用医院成本与收费比率，加上EMS和医生成本进行转换。 公共卫生相关性： 将重伤患者集中在主要创伤中心的能力具有成本效益，具有重要的公共卫生意义。该项目的结果将解决这一公共卫生优先事项中的重要知识差距，包括：在城市，郊区和农村社区环境中现场创伤分诊指南的真正年龄特异性准确性;分诊算法的潜在变化，以提高准确性;以及现场分诊的成本影响。

DESCRIPTION (provided by applicant): Proposed Approach: Out-of-hospital trauma triage is a critical component of trauma systems and the primary mechanism for concentrating seriously injured patients in major trauma centers, yet the triage guidelines have never been rigorously validated or subject to formal cost analysis. In this project, we will use a prospective, population-based, out-of-hospital injury cohort of children, adults, and elders to examine the accuracy and cost implications of the field triage guidelines, plus opportunities for improving the triage algorithm. Importance: Data-driven solutions to increase trauma system efficiency, reduce costs, and preserve valuable resources, while still maximizing injury outcomes are desperately needed. Results from this study could have substantive implications for improving the cost-effective regionalization of seriously injured patients. Objectives: The overall goals of this application are to generate unbiased age-specific estimates of decision scheme accuracy (sensitivity and specificity) among a broad, representative injury population and to closely evaluate the cost implications of field triage. Our hypothesis is that the triage guidelines have higher under- and over-triage rates than previously recognized, that triage is heavily influenced by EMS provider judgment, and that there are significant cost implications associated with mis-triage. This proposal has 3 specific aims: Specific Aim 1. Prospectively validate the field triage decision scheme among children, adults, and elders in 2 urban/suburban sites and 1 rural site using a broad out-of-hospital injury cohort. Specific Aim 2. Evaluate the utility of individual triage criteria (including EMS provider judgment) and re-derive the field trauma triage guidelines within pre-specified age strata for children, adults, and elders. Specific Aim 3. Conduct formal cost analyses of the decision scheme, including differences by hospital type and triage criteria, over- and under-triage, and the cost-effectiveness of different strategies for field triage. Study Design: Population-based, observational, consecutive patient prospective cohort. Setting: The study will be conducted in 3 sites: Portland, OR/Vancouver (4 counties); King County, WA; and Josephine County, OR (rural site). Forty-three EMS agencies and 19 acute care hospitals (3 Level I, 1 Level II, 3 Level III, 4 Level IV, and 8 non-designated community hospitals) will be included. Participants: The study will include all persons with a 9-1-1 response and EMS provider primary impression of "trauma," regardless of whether triage guidelines are met, transport destination or outcome. The EMS cohort will include 58,800 injured patients with 10,877 (the primary sample) sampled for hospital outcomes. Outcome Measures: The primary outcome will be "serious" injury (maximum Abbreviated Injury Scale score 3). The secondary outcome will be a composite measure of serious injury or trauma resource use (major operative intervention, interventional radiology, ICU stay e 2 days, transfusion, prolonged ventilation or in- hospital mortality). Costs will be translated using hospital cost-to-charge ratios, plus EMS and physician costs. PUBLIC HEALTH RELEVANCE: Project Narrative The ability to concentrate seriously injured patients in major trauma centers cost-effectively has significant public health implications. Results of this project will address important knowledge gaps in this public health priority, including: the true age-specific accuracy of field trauma triage guidelines in urban, suburban, and rural community settings; potential changes in the triage algorithm to improve accuracy; and the cost implications of field triage.