美国创伤中心的发展(2)

18HoffandSchwab

TABLECampaigns—Time1.TwentiethtoDefinitiveCenturyMilitaryCare

Campaign

MilitaryDefinitiveTimetoCare

Mortality

WorldWarI(WWI)12–18hours8.5%WorldWarII(WWII)6–12hours5.8%KoreanConflict2–4hours2.4%VietnamWar

65minutes

1.7%

DevelopmentofTraumaSystemsintheUnitedStatesInthehistoryofmedicine,traumasystemsmustbecon-sideredarelativelyrecentdevelopmentandonewhichisinitsearlyevolution.Inthelate1950sandearly1960s,severalstudiesshowedsuboptimalclinicaloutcomesincivilianpatientswithtrauma.15,16,24,28Asignificantnum-beroftraumamortalitieswerethoughttohavebeenavoid-ablewhenamoresystematicapproachtoseverelyinjuredpatientswasused.Outofthesestudies,theconceptofpreventabledeath,usedroutinelyinmodernperformanceimprovementreviews,wasidentifiedasonewaytomea-sureoutcomesintraumasurgery.

In1966,theNationalAcademyofSciencespublishedAccidentalDeathandDisability:TheNeglectedDiseaseofModernSociety,1whichhighlightedtheinferiorstateoftraumacareinthiscountryatthetime.This“whitepaper”alsodescribedthesignificantsocietalandeconomicim-plicationsassociatedwithprovidingsubstandardcaretoinjuryvictims.1Severalrecommendationsincluded:evalu-ationoftransportationmodalitiesforlesspopulatedareas;provisionofeducationalopportunitiesforprehospitalper-sonnel;completionofaresourceassessmenttodeterminewhatresourceswereactuallyavailableforthemanage-mentofseverelyinjuredpatients;establishmentofregis-triestoaccumulatedataspecifictopatientswithtrauma;andprovisionoffinancialsupportforspecializedcen-ters.12PublicationofthispapermarkedthebeginningofmodernEmergencyMedicalServices(EMS).5

Illinoisestablishedthefirstformalregionaltraumasys-temin1971.TheIllinoisTraumaProgramconsistedofdesignatedfacilitiesfortraumaandburncare,withthreecategoriesdefined:LocalTraumaCenter,AreawideTraumaServiceCenter,andRegionalTraumaServiceCenter.5TheEmergencyMedicalServicesAct(P.L.93–154)of1973providedfunding,guidelines,andtechnicalsupportforthedevelopmentofregionalizedEMSnation-wide.10ByrecognizingtheimportanceofEMSandthespecialneedsofthepatientwithtrauma,thislegislationhadsignificantinfluenceonthedevelopmentoftraumaandEMSsystems.Inaddition,theEMSActprovidedgovernmentfundingfortrainingandequippingEMSper-sonnel.4,5,19

andClinicalRelatedOrthopaedicsResearch

In1976,theAmericanCollegeofSurgeonsCommitteeonTrauma(ACS-COT)publishedOptimalHospitalRe-sourcesforCareoftheInjuredPatient.Thisdocumentestablishedacategorizationschemefortraumacentersandguidelinesfortherespectivetraumacenter.2Unfortu-nately,thedesignoftheseoriginalguidelinesexcludedmanyhospitalsfromparticipationinregionaltraumasys-tems.WiththepublicationofTheModelTraumaCareSystemPlan(1992),theconceptoftheinclusivetraumasystemwasintroduced.23Asaresult,subsequentversionsoftheACS-COTguidelineshavereflectedmoreflexibilityforindividualinstitutionsinterestedinparticipating.19ThemostrecenttraumacentercategorizationschemeisshowninTable2.

In1988,Westetal27reviewedthestatusoftraumasystemdevelopmentintheUnitedStates.Atthattime,onlytwostateshadalltheessentialcomponentsofare-gionaltraumasystem.Twenty-ninestateshadnotinitiatedanyformalprocessoftraumacenterdesignation.Amorerecentstudydocumentsthat35statesandtheDistrictofColumbiahaveformallyestablishedtraumacenters.11Clearly,EMSandtraumasystemsareevolving.TheoryofTraumaSystems

Thefollowingvignetteshowstheessentialcomponentsofatraumasysteminitsmostbasicform:

Amotorvehiclecollideswithatreeinaruralcountyandthedriverisejectedfromthevehicle.Heisfoundbyanothermotoristwhoflagsdownatruckdriverwhocalls911.Anambulancearrivesandtransportsthepatienttotheclosesthospital.Onrapidinitialsurvey,theemergencyphysicianfindsthemantobecomatoseandhypotensive,

TABLE2.

ACS-COTTraumaCenterCategories

TraumaDesignation

CenterDescription

LevelI

Clinicalcareofallaspectsofinjury

Tertiarycarefacilitycentraltothetraumasystem

Leadershiprolewithinthetraumasystem Educationandresearch Traumasystemsplanning

LevelII

Totaldefinitivecare—lesscomprehensivethanLevelI

Maybemostprevalentfacilitywithintraumasystem

LevelIII

Rapidassessment,resuscitation,emergencysurgery,stabilization

Transferformoredefinitivecare

LevelIV

ATLS-levelclinicalcarewithtransfertohigherlevelofcare

Resuscitationandclinicalcareperprotocol/guidelines

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