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1、4.4 Statistical methods: risk-adjusted mortality 4. 4统计方法：风险调整的死亡率A number of different scoring systems exist to help compare injuries between patients in an objective manner. Some of these scoring systems are based on the anatomical nature of the injuries sustained (anatomical scores) and some are
2、based on the physiological status of the patient (physiological scores). The best known and most widely used scoring systems are the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), the Glasgow Coma Scale (GCS), the Revised Trauma Score (RTS), the Trauma and Injury and Severity Score
3、 (TRISS), and A Severity Characterization of Trauma (ASCOT) (Baker, 1974;Champion, 1989; OKeefe and Jurkovich, 2001; Association for the Advancement of Automotive Medicine, 2005). A detailed comparison of the scoring systems can be found in Table 18.有许多不同的评分系统有助于客观地对照病人间的损伤程度。有些评分系统是基 于受伤的解剖学特点(解剖学得
4、分)，也有些评分系统是基于病人的生理学状况 (生理学得分)。最广为人知和广泛使用的评分系统是简略损伤量表(AIS)，损 伤严重程度评分(ISS),格拉斯哥昏迷指数(GCS),修正创伤评分(RTS),创伤损伤 严重程度评分(TRISS)，和创伤严重度(ASCOT)(贝克，1974；钱皮恩，1989； 奥基夫和尤尔科维奇，2001 ；汽车事故医学发展协会，2005)。评分系统间的详 细比照见表18。table 16 Causes of errors表16导致错误的原因Diagnostic error诊断错误Data are incorrectly perceived.病情没有被正确理解。As a
5、result, an incorrect intention is formulated and therefore the wrong action is performed.因此形成了错误的诊断，从而采取了错误的治疗方法。Example: Failure to diagnose intra-abdominal haemorrhage, and subsequent delay in operative intervention.举例：腹内大出血的误诊导致手术治疗的延误。Intention error判断错误Data are correctly perceived.病情被正确理解了。Inco
6、rrect intention is nonetheless developed and therefore the wrong action is performed.仍然产生了错误的判断，因此采取了错误的治疗行为。Example: Awareness of a threatened airway in a hypoxic, head-injured patient, but failure to take steps to clear and establish a secure airway.举例：意识到导气管对缺氧，头部受伤病人可能造成的威胁，却没有采取措施清 除并建立安全的导气管。E
7、xecution error执行错误Data are correctly perceived.病情被正确理解了。Correct intention is developed.做出了正确的判断。Wrong or unintended action is performed.采取了错误或失误的治疗行为。Example: Making the decision to secure the airway with endotracheal intubation, but misplacing the tube in the oesophagus rather than the trachea.举例：决
8、定用气管内插管法固定导气管，却误将管插入食道而不是气管。References: Reason, 1995; Chang et al., 2005; Gruen et al., 2006; Ivatury et al., 2008参考：里曾，1995；常等人，2005；格伦等人，2006；艾弗里等人，2008table 17 Summary of terms and definitions of events to be monitored, recorded, and tracked表17术语摘要以及监测，记录和追踪的事件定义Term术语Definition定义Complication并发症U
9、nexpected, unplanned and unwanted outcomes such as a wound infection or a deep venous thrombosis. Can be secondary to natural disease processes or an adverse event.比如像伤口感染或深静脉血栓这样意外的后果是疾病过程自然次生的或不良事 件。Adverse event不良事件“An injury that is caused by medical management rather than the underlying disease
10、 and that prolongs hospitalization, produces a disability at discharge, or both.” (Institute of Medicine, 2001a)由医疗管理而不是潜在疾病引起的损伤，从而延长了住院治疗的时间，导致了伤 残，或者两者兼有。(医药协会，2001)Error过失“Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim” (Institute of Medicine, 19
11、99)没能完成预定的诊疗方案或者采用错误的方案进行治疗(医药协会，1999)Sentinel event警讯事件A subtype of adverse event with a particularly high potential for harm. “An unexpected occurrence resulting in death or serious physical or psychologicalinjury, or the risk thereof.” (JCA5O，2一个不良事件的子类型具有非常高的潜在损伤风险。*意外的发生将导致死亡或 严重的身体或心理损害，或因此产生的
12、严重风险*Audit filters监视过滤器Pre-identified standards that are routinely tracked and flagged if particular criteria for accepted standards of care are not met. Any of the preceding items in this table may also be used as audit filters.如果采用的治疗标准没有满足要求的指标，将事先确定的标准用于一般的追踪和 标记。此表先前列出的任何一项可用做监视过滤器。Through such
13、 statistical processes, hospitals evaluate the percentage of deaths occurring in patients with low Injury Severity Scores or a low probability of death based on either one score (e.g. ISS) or on a combination of scores such as the ISS and RTS (TRISS methodology) (Boyd, Tolson and Copes, 1987).凭借这样的统
14、计程序，医院用低损伤严重程度评分系统或以任一评分系统(如 ISS)或某个联合评分系统如ISS和RTS(TRISS方法学)为基础的低死亡几率来 评估病人死亡率(博伊特，托尔森和科普森，1987)。Additionally, a trauma QI programme can set up a system to evaluate unexpected deaths identified by the various scoring systems. For example, the trauma QI programme can mandate examination of all deaths
15、 in patients with minor injuries as identified by an ISS of less than 9 or with probability of survival (Ps) greater than 90% as calculated by TRISS to make sure that an appropriate level of care was achieved.此外，一个创伤质量改进项目可以建立起一套可评估由不同评分系统鉴定的意外 死亡的体系。例如，创伤质量指标项目可以要求对所有病人的死亡检查ISS小 于9或由TRISS计算出幸存率（Ps）
16、大于90%的微小损伤，来确保达到了适当 护理水平。Use of statistical methods also allows a hospital to compare itself against predetermined national or international norms. Hospitals with risk-adjusted death rates higher than expected may warrant evaluation of individual unexpected deaths along with evaluation of the systems of care in order to identify elements that may contribute to such h
