医师配备的急诊医学系统中院前时间与院内创伤死亡率的关联。,JAMA Surgery

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医师配备的急诊医学系统中院前时间与院内创伤死亡率的关联。
JAMA Surgery ( IF 15.7 ) Pub Date : 2019-12-01 , DOI: 10.1001/jamasurg.2019.3475
Tobias Gauss ₁ , François-Xavier Ageron ₂ , Marie-Laure Devaud ₃ , Guillaume Debaty ₄ , Stéphane Travers ₅ , Delphine Garrigue ₆ , Mathieu Raux _{7,

8} , Anatole Harrois ₉ , Pierre Bouzat ₁₀ ,

Affiliation

Department of Anesthesia and Critical Care, Hôpital Beaujon, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique-Hôpitaux de Paris, Clichy, France.
Trauma System of the Northern French Alps Emergency Network (Trauma System du Réseau Nord Alpin des Urgences [TRENAU]), Hospital Annecy Genevois, Annecy, France.
Prehospital Emergency Medicine Service (Service Aide Medicale Urgente 95), Centre Hospitalier René Dubos, Pontoise, France.
Department of Emergency Medicine, Service Aide Medicale Urgente 38, University Hospital of Grenoble Alps, Grenoble, France.
Paris Fire Brigade Emergency Medical Department, French Military Health Service, Paris, France.
Interdisciplinary Emergency Platform, Department of Anesthesia and Critical Care, University Hospital, Lille, France.
Department of Anesthesia and Critical Care, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Trust Pitié-Salpêtrière, Paris, France.
Unité Mixte de Recherche Scientifique 1158, Clinical and Experimental Respiratory Neurophysiology, Institut National de la Santé et de la Recherche Médicale, Paris, France.
Department of Anesthesiology and Critical Care, University Paris Sud, University Paris Saclay, Assistance Publique-Hôpitaux de Paris, Bicêtre University Hospital Paris Sud, Le Kremlin-Bicêtre, France.
Department of Anesthesia and Critical Care, University Hospital, Grenoble, France.

重要性住院前总时间与医生配备的创伤系统中的死亡率之间的关联仍不确定。目的描述法国院前，医生配备的创伤系统中院前总时间与院内死亡率的关联，并提出以下假设：院前总时间与死亡率增加相关。设计，背景和参与者这项队列研究于2009年1月至2016年12月进行。该研究的数据来自法国的2个不同的区域创伤登记处（1个城市和1个农村地区），均设有由医生配备的紧急医疗服务。研究期间纳入了两个区域性创伤转诊中心之一的连续成人创伤患者。数据分析时间为2018年3月至2018年9月。主要结果和措施死亡和院前时间之间的关联通过使用混杂因素调整的多变量模型进行评估。院前总时间是主要的暴露变量，记录为从医师领导的院前护理小组到达现场到到达医院的时间。感兴趣的主要结果是全因医院内死亡率。结果纳入主要受非穿透性伤害影响的10 216名患者（平均[SD]年龄，41 [18]岁； 7937名男性[78.3％]），平均（SD）伤害严重度（9265 [91.5％]）得分17（14）分。在这些患者中，有6737名（66.5％）的身体部位至少为1个，而简短伤害量表的得分为3或更高。共有1259例患者（12.4％）表现为休克（收缩压<90 mm Hg）和2724例（26。9％）患有严重的颅脑损伤（缩写为Scale≥3分）。在未经调整的分析中，院前时间的增加（在30分钟类别中）与院内死亡风险的显着且持续的增加相关。院前时间每增加10分钟，死亡几率增加9％（赔率，1.09 [95％CI，1.07-1.11]），调整后增加4％（赔率，1.04 [95％CI，1.01-1.0] 1.07]）。结论与相关性在这项研究中，经过病例复杂性调整后，在由医生配备的紧急医疗系统中，创伤前患者的总院前时间增加与院内全因死亡率增加相关。院前时间是类似于生理目标的管理目标。

"点击查看英文标题和摘要"

Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System.

Importance The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain. Objective To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality. Design, Setting, and Participants This cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018. Main Outcomes and Measures The association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality. Results A total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 (14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score ≥3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]). Conclusions and Relevance In this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

更新日期：2019-12-19

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