美国创伤中心的发展(2)

Maybemostprevalentfacilitywithintraumasystem

LevelIII

Rapidassessment,resuscitation,emergencysurgery,stabilization

Transferformoredefinitivecare

LevelIV

ATLS-levelclinicalcarewithtransfertohigherlevelofcare

Resuscitationandclinicalcareperprotocol/guidelines

NumberMay2004

422withaseverelydeformedleftfemurandobviousopenleftanklefracture.Thepatientisintubatedimmediately,intra-venousaccessisobtained,andfluidsareadministered.Recognizingthelimitedresourcesavailableathishospital,theemergencyphysiciancontactstheclosesttraumacenterandarrangementsaremadetotransportthepatientbyhelicopterwhileactiveresuscitationproceeds.Atthetraumacenter,themanreceivesdefinitivetreatmentforhisneuro-logicandorthopaedicinjuries,fromwhichherecoverswith-outcomplication.Hesubsequentlyistransferredtoaninpa-tientrehabilitationfacilityandsubsequentlyreturnedhomewitharrangementsforfollowupwithanorthopaedicsurgeoninhiscommunity.

In1990,theTraumaCareSystemsPlanningandDe-velopmentActmandatedthedevelopmentofaglobaltraumaplan.Asaresult,theBureauofHealthResourcesDevelopmentconvenedagroupofconsultantstowritetheModelTraumaCareSystemsPlan,whichremainsthees-sentialtextontraumasystems.23Theplanwasthefirstiterationoftheessentialcomponentsofaninclusivetraumasystem.Beforethisinnovation,traumasystems,basedontheguidelinessetforthbytheACS-COT,con-sistedofhospitalsthatchosetoberecognizedfortheircommitmenttocaringforpatientswithtrauma.Thesefa-cilitiesweredesignatedastraumacenters(exclusivetraumasystem).

Inaninclusivetraumasystem,thecontributionsofallhealthcarefacilitiestothecareofpatientswithtraumaandproviderswithinageographicareaarerecognizedregard-lessofdesignationasatraumacenter.ThemajorityofpatientswithtraumahaveinjurieswhichareclassifiedasminorormoderateanddonotrequiretheresourcesofaLevelIorIItraumacenter(Fig1).Therefore,theabilityofallacutecarehospitalstotreatinjuredpatientsmustbeconsideredwiththecaveatthatallfacilitieshavesomelinkagetoaLevelIorIItraumacenter.3Theultimategoalistomatchtheresourcesofthefacilityorprovidertotheneedsoftheinjuredpatient.

TheessentialcomponentsofthemoderntraumasystemareshowninFigure2.Activitiesshownontheringfacili-tateandsupportthecentralcomponentsofthesystem.Trainingforalllevelsofprovidersensuresoptimalclinicalcareforpatients.Populationandinjury-specificpreventionandoutreachactivitiesareintendedtoreducetheoverallincidenceandseverityoftrauma.Finally,thetraumasys-temmusthavesomeprovisionforcontinuousperformanceimprovementandevaluation.Tomaintainsuccessfulac-creditation,individualtraumacentersmustshowactiveperformanceimprovementprograms.Fromasystem-wideperspective,regularsitevisitsdonebyteamsofoutsidesurveyorsensurethatindividualtraumacenterscontinuetomeetestablishedstandards.

TraumaSystemDevelopmentinNorthAmerica19

Fig1.ThegraphshowstheInclusiveTraumaCareSystem.(ReprintedwithpermissionfromtheU.S.DepartmentofHealthandHumanServices,Washington,DC.)

Thecentralcoreconsistsoftheclinicalcomponentsrequiredforpatientcare.Prehospitalcarerequireseffec-tivecommunicationandreliablemedicalcommand.Ap-propriatematchingofpatientstoresourcesentailstriagecriteriathatmaybeappliedeasilyinthefield.A

discus-

Fig2.ThegraphshowstheessentialcomponentsofanIn-clusiveTraumaCareSystem.(ReprintedwithpermissionfromtheU.S.DepartmentofHealthandHumanServices,Wash-ington,

DC.)

20HoffandSchwab

sionspecifictothecomplexissueoftriageinanorganizedtraumasystemispresentedinSectionX.Reliablecom-municationsystemsandrapiddispatchofprehospitalpro-vidersarenecessarytominimizetimetoaccess.Trans-portationofvarioustypesshouldbeavailabletoaccom-modategeography,populationdensity,andvariableenvironmentalconditions.Inacompletetraumasystem,therolesofeachacutecarefacilityinagivenregionmustbedelineatedwithrespecttotraumacare.Traumacentersideallyshouldbedesignatedbasedonestablishedcriteriaandpopulationdensity.Specialtycenterstypicallyaredes-ignatedtocareforpatientswithburns,pediatricpatientswithtrauma,andpatientswithspinalcordinjuries.Be-causetheywillberesponsibleforthemajorityofinjuredpatients,theactualroleofallhospitalsintraumacaremustbeestablished.Itisvitalthatallhospitalsdevelopformal-izedrelationshipswithdesignatedtraumaandspecialtycenterstoensurethat,whennecessary,patientshavereadyaccesstohigherlevelsofcare.Integratedrehabilitationservicesspecifictotheneedsofthepatientwithtraumacompletestheclinicalcomponentsofthetraumasystem.Aneffectivetraumasystemrequiresastrongadminis-trativeinfrastructure,asshownintheouterringofFigure2.Atsomelevel,legislationisnecessarytoestablishthetraumasystemasanentity,assignoverallauthorityforthesystem,anddirectnecessaryfunding.Aleadagency(gov-ernmentalorprivate)mustbechargedwithoversightofthesystem.Suchoversightincludesdesignationoftraumacenters;regularevaluationoftraumacentersasdescribedpreviously(externalevaluationoraccreditation);andcon-tinuousqualityimprovement(internalevaluation)ofallcomponentsofthetraumasystem.Theleadagencyas-sumesresponsibilityforsystemdevelopment.Onacon-tinuousbasis,theneedsoftheregionandtheavailableresourcesshouldbeassessedtodeterminewhetherthesystemrequiresmodification.

Thefiscalaspectsofatraumasystemcannotbeig-nored.Unfortunately,thefinancialcommitmentassociatedwithtraumacenterdesignationandaccreditationisamajorimpedimenttoinvolvementformanyinstitutions.Further-more,economicissueshavebeenreportedasonefactorthathasforcedmanytraumacenterstogiveuptheirdes-ignation.Therefore,theestablishmentandsurvivalofor-ganizedsystemsoftraumacarearedependentonfinancialsupportasoneoftheessentialadministrativecomponents.EffectivenessofOrganizedSystemsofTraumaCareTojustifythetremendousresourcesrequiredtoestablishandmaintaintraumacentersandtraumasystems,itises-sentialthattheybeeffective.Numerousstudiesintheliteraturehavedocumentedthebenefitsoforganizedtraumasystemsonpatientoutcome.6,9,13,16,17,20,21,26Thissectionwillhighlightsomeoftheclinicalstudiesthatcom-

andClinicalRelatedOrthopaedicsResearch