美国创伤中心的发展(5)

NumberMay2004

422specifictothetreatmentofpatientswithtraumawouldberecognized.Animportantpartoftheresourceassessmentofagiveninstitutionistheinternaldisasterplan.Beforeanycatastrophicevent,theresponsivenessanddepthofeachhealthcarefacilityinagivenregionwouldbeestab-lishedclearly;(2)Regularlyscheduledsiteevaluationsensurethatestablishedstandardsaremetbyalldesignatedtraumacentersinaregionalsystem(theaccreditationpro-cess);(3)ActiveinvolvementofallEMScomponents(po-lice,fire,basiclifesupportandadvancedlifesupport)withoversightbytheleadorganizationwouldprovideanorga-nizedapproachintheprehospitalphaseofcare.Suchanapproachwouldincludeadisasterplanthatisreviewedonaregularbasis;(4)Anestablishedsetoffieldtriagecri-teriawouldaimtomatchinjuryseveritywiththeappro-priateresources.Therefore,especiallyinthemasscasualtyscenario,tertiarytraumacarecenters(LevelsIandII)arenotinundatedwithminimallyinjuredpatientswhocouldbetreatedsafelyatLevelIIIorLevelIVtraumacentersoracommunityhospitalwithintheregion;(5)Continuousadministrativeoversightestablishedtodoregularneedsassessmentoftheregion,ensurequalityimprovement,andidentifyareasforeducationatalllevels;(6)Communica-tionofthehighestlevelbetweenallcomponents(prehos-pital,intrafacility)withpredeterminedlinkstoprovideim-mediateavailabilityofthenecessaryresourcesand,whennecessary,interfacilitytransfer.

Unfortunately,regionaltraumasystemsarenotavail-ableuniversally.Althoughmorepopulation-denseareasusuallyhavesomeversionofatraumasysteminplace,approximately40%oftheUnitedStatespopulationlivesinstateswithoutatraumasystem.14Moreover,manyex-istingsystemslackessentialcomponentsasoutlinedintheModelTraumaCareSystemPlan.Manysystemsarenottrulyinclusive.Asaresult,thereisnodefinedroleforthenondesignatedhospital,particularlyduringregionaldisas-terormasscasualtysituations.Intrafacilityandregionaldisasterplansareessentialtooptimizetreatmentinthefaceoflargescalecasualties.8Aneffectiveregionaltraumasystemlogicallyfacilitatesallaspectsofdisasterplanningandworkstooptimizepatientcareduringextremesitua-tions.

Comparedwithmanyoftheclinicaladvancementsintraumacare,traumasystemdevelopmentisarelativelynewconcept.Traumasystemshavetheirrootsinmilitarymedicine,whereitwasrecognizedthatoutcomescouldbeimprovedbydevisingmethodstoreducethetimetode-finitivecare.Basedonthemilitarymodel,civiliantraumacentersbegantoevolveinthe1970s.Thesuccessofor-ganizedtraumacarewithrespecttopatientoutcomehasbeenshown.Apopulation-basedstudyreporteda9%re-ductionincrudemortalityrateforstateswithtrauma

TraumaSystemDevelopmentinNorthAmerica21

systems.14Basedonthisstatistic,moreuniversalavail-abilityoftraumasystemswouldresultinthousandsoflivessaved.

Asintimeofwar,asystemsapproachtotraumacareideallyissuitedtothecivilianmasscasualtyscenario.Unfortunately,therearemanyobstaclestofulldevelop-mentoftraumasystemsintheUnitedStates.Individualtraumacentersrequireextensivecommitmentofmaterialandpersonnelresourcesandmanyhospitalsarenotwillingtoriskfiscalshortfalls.Insomestates,thecostofmedicalmalpracticeinsurancehaslimitedtheavailabilityofsub-specialistsnecessarytomaintaintraumacenteraccredita-tion.Thepoliticalimplicationsoftraumacenterdesigna-tionalsoremainasignificantissue;theeffectonnondes-ignatedhospitalsisusedfrequentlytolimitexpansionoftraumasystems.

Traumasystemdevelopmentmustbeencouragedtoensureastateofpreparedness.Now,morethanever,gov-ernmentagenciesandtheprivatesectorshouldfacilitatemovementtowardaModelTraumaCareSystem.Re-cently,theNationalTraumaStakeholders(NTS)groupwasestablishedtoadviseandprovidecounseltotheDe-partmentofHealthandHumanServices.Hopefully,theinfluenceofgroupsliketheNTScangeneratearenewedsenseofenthusiasmabouttraumasystemsdevelopmentforthesakeofthecitizens.References

1.AccidentalDeathandDisability:TheNeglectedDiseaseofModernSociety.Washington,DC,NationalAcademyofSciencesandtheNationalResearchCouncil1966.

2.AmericanCollegeofSurgeonsCommitteeonTrauma:Optimalhospitalresourcesforcareoftheseriouslyinjured.BullAmCollSurg61:15–22,1976.

3.AmericanCollegeofSurgeonsCommitteeonTrauma:ResourcesforOptimalCareoftheInjuredPatient:1999.Chicago,AmericanCollegeofSurgeons1998.

4.BockBF,BerkWA,BonnerSC,etal:PrehospitalMedicalCareoftheInjuredPatient.InWilsonRF,WaltAJ(eds).ManagementofTrauma:PitfallsandPractice.Ed2.Baltimore,Williams&Wilkins1-12,1996.

5.BoydDR,CowleyRA:Comprehensiveregionaltrauma/emergencymedicalservices(EMS)systems:TheUnitedStatesexperience.WorldJSurg7:149–157,1983.

6.CalesRH:TraumamortalityinOrangeCounty:Theeffectofimple-mentationofaregionaltraumasystem.AnnEmergMed13:1–10,1984.

7.DavisJH:HistoryofTrauma.InFelicanoDV,MooreEE,MattoxKL(eds).Trauma.Ed3.Stamford,CT,Appleton&Lange3-13,1996.

8.Feeney:ParekhP,BlumenthalJ,etal:September11,2001:Atestofpreparednessandspirit.BullAmCollSurg87:12–17,2002.9.HedgesJR,MullinsRJ,Zimmer-GembeckM,etal:OregonTraumaSystem:Changeininitialadmissionsiteandpost-admissiontransferofinjuredpatients.AcadEmergMed1:218–226,1994.

http://www.77cn.com.cnwofthe93rdCongress,EmergencyMedicalServicesSystems

Actof1973.PublicLaw93-154.Washington,DCNovember16,1973.

11.MacKenzieEJ,HoytDB,SacraJC,etal:Nationalinventoryof

hospitaltraumacenters.JAMA289:1515–1522,2003.

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