疾病預(yù)防統(tǒng)計(jì)學(xué)分析方法

1、4.4 Statistical methods: risk-adjusted mortality 4. 4統(tǒng)計(jì)方法：風(fēng)險(xiǎn)調(diào)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.有許多不同的評分系統(tǒng)有助于客觀地對照病人間的損傷程度。有些評分系統(tǒng)是基 于受傷的解剖學(xué)特點(diǎn)(解剖學(xué)得

4、分)，也有些評分系統(tǒng)是基于病人的生理學(xué)狀況 (生理學(xué)得分)。最廣為人知和廣泛使用的評分系統(tǒng)是簡略損傷量表(AIS)，損 傷嚴(yán)重程度評分(ISS),格拉斯哥昏迷指數(shù)(GCS),修正創(chuàng)傷評分(RTS),創(chuàng)傷損傷 嚴(yán)重程度評分(TRISS)，和創(chuàng)傷嚴(yán)重度(ASCOT)(貝克，1974；錢皮恩，1989； 奧基夫和尤爾科維奇，2001 ；汽車事故醫(yī)學(xué)發(fā)展協(xié)會(huì)，2005)。評分系統(tǒng)間的詳 細(xì)比照見表18。table 16 Causes of errors表16導(dǎo)致錯(cuò)誤的原因Diagnostic error診斷錯(cuò)誤Data are incorrectly perceived.病情沒有被正確理解。As a

5、result, an incorrect intention is formulated and therefore the wrong action is performed.因此形成了錯(cuò)誤的診斷，從而采取了錯(cuò)誤的治療方法。Example: Failure to diagnose intra-abdominal haemorrhage, and subsequent delay in operative intervention.舉例：腹內(nèi)大出血的誤診導(dǎo)致手術(shù)治療的延誤。Intention error判斷錯(cuò)誤Data are correctly perceived.病情被正確理解了。Inco

6、rrect intention is nonetheless developed and therefore the wrong action is performed.仍然產(chǎn)生了錯(cuò)誤的判斷，因此采取了錯(cuò)誤的治療行為。Example: Awareness of a threatened airway in a hypoxic, head-injured patient, but failure to take steps to clear and establish a secure airway.舉例：意識到導(dǎo)氣管對缺氧，頭部受傷病人可能造成的威脅，卻沒有采取措施清 除并建立安全的導(dǎo)氣管。E

7、xecution error執(zhí)行錯(cuò)誤Data are correctly perceived.病情被正確理解了。Correct intention is developed.做出了正確的判斷。Wrong or unintended action is performed.采取了錯(cuò)誤或失誤的治療行為。Example: Making the decision to secure the airway with endotracheal intubation, but misplacing the tube in the oesophagus rather than the trachea.舉例：決

8、定用氣管內(nèi)插管法固定導(dǎo)氣管，卻誤將管插入食道而不是氣管。References: Reason, 1995; Chang et al., 2005; Gruen et al., 2006; Ivatury et al., 2008參考：里曾，1995；常等人，2005；格倫等人，2006；艾弗里等人，2008table 17 Summary of terms and definitions of events to be monitored, recorded, and tracked表17術(shù)語摘要以及監(jiān)測，記錄和追蹤的事件定義Term術(shù)語Definition定義Complication并發(fā)癥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.比如像傷口感染或深靜脈血栓這樣意外的后果是疾病過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)由醫(yī)療管理而不是潛在疾病引起的損傷，從而延長了住院治療的時(shí)間，導(dǎo)致了傷 殘，或者兩者兼有。(醫(yī)藥協(xié)會(huì)，2001)Error過失“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)沒能完成預(yù)定的診療方案或者采用錯(cuò)誤的方案進(jìn)行治療(醫(yī)藥協(xié)會(huì)，1999)Sentinel event警訊事件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，2一個(gè)不良事件的子類型具有非常高的潛在損傷風(fēng)險(xiǎn)。*意外的發(fā)生將導(dǎo)致死亡或 嚴(yán)重的身體或心理損害，或因此產(chǎn)生的

12、嚴(yán)重風(fēng)險(xiǎn)*Audit filters監(jiān)視過濾器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.如果采用的治療標(biāo)準(zhǔn)沒有滿足要求的指標(biāo)，將事先確定的標(biāo)準(zhǔn)用于一般的追蹤和 標(biāo)記。此表先前列出的任何一項(xiàng)可用做監(jiān)視過濾器。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).憑借這樣的統(tǒng)

14、計(jì)程序，醫(yī)院用低損傷嚴(yán)重程度評分系統(tǒng)或以任一評分系統(tǒng)(如 ISS)或某個(gè)聯(lián)合評分系統(tǒng)如ISS和RTS(TRISS方法學(xué))為基礎(chǔ)的低死亡幾率來 評估病人死亡率(博伊特，托爾森和科普森，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，一個(gè)創(chuàng)傷質(zhì)量改進(jìn)項(xiàng)目可以建立起一套可評估由不同評分系統(tǒng)鑒定的意外 死亡的體系。例如，創(chuàng)傷質(zhì)量指標(biāo)項(xiàng)目可以要求對所有病人的死亡檢查ISS小 于9或由TRISS計(jì)算出幸存率（Ps）

16、大于90%的微小損傷，來確保達(dá)到了適當(dāng) 護(hù)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 system

17、s of care in order to identify elements that may contribute to such higher risk-adjusted mortality.統(tǒng)計(jì)學(xué)方法的使用也使醫(yī)院能夠?qū)⒆陨砗皖A(yù)設(shè)的國內(nèi)或國際標(biāo)準(zhǔn)進(jìn)行比照。風(fēng)險(xiǎn) 調(diào)整死亡率比預(yù)期高的醫(yī)院可以授權(quán)對個(gè)人意外死亡以及治療體系進(jìn)行評估，以 期鑒別出導(dǎo)致如此高的風(fēng)險(xiǎn)調(diào)整死亡率的因素。Any of the above-noted risk-adjustment methods add increased objectivity to the QI process. However, it must

18、 be noted that they also increase resource requirements, especially in terms of staff time for injury severity coding.任何上面提到的風(fēng)險(xiǎn)調(diào)整方法都增加了質(zhì)量改進(jìn)程序的客觀性。然而必須注意它 們也增加了對資源的需求，尤其是員工用于鑒別損傷嚴(yán)重程度的時(shí)間。table 18 Scoring system for severity of injury表18損傷嚴(yán)重程度的評分系統(tǒng)System系統(tǒng)Definition定義Abbreviated Injury Scale (AIS)簡略損傷量

19、表(AIS)Anatomical score. The purpose of the AIS was to catalogue anatomical injuries sustained in motor vehicle collisions. It was developed in 1971 and revised in 1990 by the Association for the Advancement of Automotive Medicine, the American Medical Association and the Society of Automotive Engine

20、ers. Injuries are designated according to six body areas and are ranked on a scale from AIS 1 (least severe) to AIS 6 (most severe).解剖學(xué)分?jǐn)?shù)。這個(gè)簡略損傷量表的目的是將機(jī)動(dòng)車碰撞導(dǎo)致的解剖學(xué)損傷進(jìn)行分 類。它在1971年建立起來并在1990年由汽車事故醫(yī)學(xué)發(fā)展協(xié)會(huì)，美國醫(yī)藥協(xié) 會(huì)和汽車工程協(xié)會(huì)進(jìn)行修改。損傷根據(jù)六個(gè)身體區(qū)域進(jìn)行命名，并根據(jù)簡略損傷 量表1(最輕程度)到6 (最終程度)進(jìn)行分級。Injury Severity Score (ISS)損傷嚴(yán)重程度評分

21、(ISS)Anatomical score. This was developed in 1974 and revised in 1997 (the New ISS, or NISS). It utilizes the AIS system to create a summary score. The ISS is derived from the sum of the squares of the highest AIS scores from each of up to three body regions. ISS can range from 1 to 75 and reflects

22、the likelihood of mortality. A common perspective is that ISS less than or equal to 9 represents a minor injury, from 10-24 is considered a moderate combination of injuries, and greater than 24 represents a severely injured patient. ISS is used to quantify injury objectively and also to assist in es

23、timating the likelihood of survival.解剖學(xué)評分。它是在1974年建立起來，1997年進(jìn)行修改(新ISS或NISS)。 它利用AIS系統(tǒng)產(chǎn)生簡要的評分。ISS是從多達(dá)三個(gè)身體區(qū)域的各自最高的AIS 評分方陣的總和衍生而來的ISS范圍可以從1到75并反映了死亡率的可能性。 通常認(rèn)為ISS少于或等于9代表輕微損傷，介于10-24認(rèn)為是中等混合損傷， 高于24代表嚴(yán)重?fù)p傷病人。ISS用于客觀地量化損傷并有助于估算幸存可能性。Glasgow Coma Scale (GCS)格拉斯哥昏迷指數(shù)(GCS)Physiological score. Reported in 19

24、70 from Glasgow, Scotland, the GCS is an objective estimate of central nervous system function according to level of consciousness. GCS is based on valuations of the functions of motor response, verbal response, and eye-opening. Scores range from 3 to 15. It is simple and reproducible with low varia

25、bility but is limited to use in patients with head injury.生理學(xué)評分。1970年蘇格蘭的格拉斯哥報(bào)道，GCS是一種基于意識水平對中 央神經(jīng)系統(tǒng)功能進(jìn)行的客觀評估。GCS以對運(yùn)動(dòng)神經(jīng)，語言和睜眼的反應(yīng)功 能的評估為基礎(chǔ)。分?jǐn)?shù)范圍從3到15。它變化性低，簡單并易于重復(fù)但是僅 限于對重傷病人的使用。Revised Trauma Score (RTS)修正創(chuàng)傷評分(rts)Physiological score. This expands physiological scoring from isolated head injury, as r

26、eflected by GCS, to a patients overall physiological status. It incorporates central nervous system function, plus functional status of the respiratory and circulatory systems. It is based on GCS, systolic blood pressure and respiratory rate.生理學(xué)評分。它的評分從單獨(dú)的頭部損傷擴(kuò)展到病人整體生理狀況，正如GCS 反映的。它合并了中央神經(jīng)系統(tǒng)的功能，加上呼吸

27、和循環(huán)系統(tǒng)的功能狀況，基于 GCS，收縮血壓和呼吸頻率。Trauma and Injury Severity Score (TRISS)創(chuàng)傷損傷嚴(yán)重程度評分(TRISS)Physiological and anatomical score. A method used to assign the probability of survival (Ps) to an individual patient after injury, this is based on a combination of RTS, ISS, mechanism of injury (blunt versus penet

28、rating), and age. Limitations exist, but overall it is an objective measure of the likelihood of survival. TRISS is often used to assign a correlating calculated probability of survival for each patient, ranging from 0-100%.1生理學(xué)和解剖學(xué)評分。該方法用于確定每個(gè)病人受傷后的幸存可能性(Ps)，以 RTS,ISS,損傷機(jī)制(穿刺鈍感)和年齡的結(jié)合為基礎(chǔ)。雖仍有局限性，但總的

29、 來說仍是幸存可能性的客觀評價(jià)方法，范圍從0-100%。A Severity Characterization Of Trauma (ASCOT)創(chuàng)傷嚴(yán)重度(ASCOT)Physiological and anatomical score. Developed to address the limitations of TRISS, this uses a more complete set of data. While TRISS has three major predicting variables, ASCOT uses seven predicting variables to ca

30、lculate a probability of survival. Although it is an attempt to improve the reliability of TRISS, ASCOT is not as widely used because of the complexity associated with collecting the data and calculating ASCOT.生理學(xué)和解剖學(xué)評分。該方法用來解決TRISS的局限性，它使用的是更完整的 系列數(shù)據(jù)。而TRISS有三個(gè)主要的預(yù)測因素，ASCOT使用七個(gè)預(yù)測因素來計(jì) 算幸存概率。盡管它是為了提高T

31、RISS可靠性而做的嘗試，由于收集數(shù)據(jù)和計(jì) 算ASCOT的復(fù)雜性，ASCOT并未得到廣泛的應(yīng)用。1 Ps may be calculated by the following formula: Ps = 1/(1 + e), where b = b0 + b1(RTS) + b2(ISS) + b3(A). e is the base of the natural logarithm: 2.71828.RTS is the revised trauma score, ISS the Injury Severity Score, and A is a variable for age (0 fo

32、r age 55). b0 -b3 are coefficients derived from using the reference databases that contain large numbers of patients from multiple institutions and thus are considered as norms against which individual patients and individual institutions can be compared.幸存概率可以用下面的方程式進(jìn)行計(jì)算：幸存概率=1/(1+e), b=b0+b1(修正創(chuàng)傷

33、評分)+b2(損傷嚴(yán)重程度評分)+b3(A).e是自然對數(shù)的基數(shù)：2.71828。RTS是修 改后的創(chuàng)傷分?jǐn)?shù)，ISS是創(chuàng)傷嚴(yán)重程度評分，A是年齡變量(0表示年齡小于55,1 表示年齡大于55)。b0-b3是從包含多個(gè)體系眾多病人的參考數(shù)據(jù)庫衍生而來的 系數(shù)，因此可以被認(rèn)為是單個(gè)病人和單個(gè)體系可被比較的準(zhǔn)則。The most extensively utilized database has been the MTOS (Major Trauma Outcome Study, from the USA in the 1980s), from which the following coeffic

34、ients were derived: Blunt trauma: b0 = -1.2470; b1(RTS) = 0.9544; b2(ISS) = -0.0768; b3(age) = -1.9052; Penetrating trauma: b0 = -0.6029; b1(RTS) = 1.1430; b2(ISS) = -0.1516; b3(age) = -2.6676.最廣泛使用的數(shù)據(jù)庫一直是MTOS(主要?jiǎng)?chuàng)傷結(jié)果研究，來自二十世紀(jì)八十年代 的美國)，從中得出下面的系數(shù):鈍感創(chuàng)傷：b0=-1.2470;b1(修正創(chuàng)傷 評 分)=0.9544;b2(損傷嚴(yán)重程度評分)=-0.076

35、8;b3(年齡)=-1.9052;穿刺創(chuàng)傷： b0=-0.6029;b1(修正創(chuàng)傷)=1.1430;b2(損傷嚴(yán)重程度評分)=-0.1516;b3(年 齡)=-2.6676。The above figures were used extensively in calculation of Ps for research and QI work. The above figures are somewhat outdated, but are provided for completeness, as they have been heavily utilized in the literatu

36、re. They were updated several years later to reflect recalibration based on updated AIS-90 coding: Blunt trauma: b0 = -0.4499; b1(RTS) = 0.8085; b2(ISS) = -0.0835; b3(age) = -1.7430; Penetrating trauma: b0 = -2.5355; b1(RTS) = 0.9934; b2(ISS) = -0.0651; b3(age) = -1.1360.上面的數(shù)字有些過時(shí)了，但由于它們被大量的使用在文獻(xiàn)里，數(shù)

37、據(jù)仍很完整。它 們在幾年后被更新，反映了基于更新的AIS-90代碼的重新校準(zhǔn)：鈍感創(chuàng)傷： b0=-0.4499;b1（修正創(chuàng)傷）=0.8085;b2（損傷嚴(yán)重程度）=-0.0835;b3（年 齡）=-1.7430;穿刺創(chuàng)傷：b0=-2.5355;b1 （修正創(chuàng)傷）=0.9934;b2（損傷嚴(yán)重程 度）=-0.0651;b3（年齡）=-1.1360。Data from the MTOS are now 20 years old. A newer reference database, the National Trauma Data Bank of the American College of

38、 Surgeons, has been developed. It is anticipated that a newer risk-adjustment model for calculating Ps based on this database will be developed in the following few years and that this will supersede the above-noted TRISS/MTOS method.來自MTOS的數(shù)據(jù)現(xiàn)已有20年之久。一個(gè)更新的參考數(shù)據(jù)庫，美國外科醫(yī)生學(xué) 院的國家創(chuàng)傷數(shù)據(jù)庫建立了。預(yù)計(jì)一個(gè)以這個(gè)數(shù)據(jù)庫為基礎(chǔ)的更新

39、的計(jì)算幸存率 的風(fēng)險(xiǎn)調(diào)整模式將 會(huì)在接下來的幾年里建立起來，這將取代上面提到的 TRISS/MTOS 方法。References: Baker, 1974; Boyd, Tolson and Copes., 1987; Champion, 1989;Champion et al., 1990; Champion, Sacco and Copes, 1995; Association for the Advancement of Automotive Medicine, 2005; American College of Surgeons, 2009參考：貝克，1974；博伊德，托爾森和科普森，

40、1987；錢皮恩，1989；錢皮恩 等人，1990；錢皮恩，薩科和科普森，1995；汽車事故醫(yī)學(xué)發(fā)展協(xié)會(huì)，2005； 美國外科醫(yī)生學(xué)院，20094.5 Corrective strategies and closing the loop4.5糾正性策略和閉環(huán)As described in section 2.2, an essential foundation of a successful QI programme is to develop and institute corrective strategies to address the problems identified, and

41、 then to evaluate and document the effectiveness of these strategies. Definitions and examples of some of the main corrective strategies utilized are given below.正如在2.2章節(jié)里描寫的，一個(gè)成功的質(zhì)量改進(jìn)項(xiàng)目的重要基礎(chǔ)是發(fā)展和建立糾 正性策略來解決確認(rèn)的問題，然后評估并記載這些策略的有效性。下面給出的是 一些主要采用的糾正性策略的定義和例子。Guidelines, pathways, and protocols指南，路徑和醫(yī)療方案G

42、uidelines are defined as systematically developed consensus statements that are designed to assist in clinical decision-making and that usually focus on diagnosis and treatment (Performance Improvement Subcommittee of the American College of Surgeons Committee on Trauma, 2002). Guidelines are usuall

43、y general in nature and often rated by the power of evidence. Guidelines are commonly developed by societies for surgical, trauma and critical care with the goal of education and dispersing knowledge on the subject of appropriate care. Published practice guidelines provide evidence-based documents f

44、rom which institution-specific pathways and protocols can be developed.指南被定義為是系統(tǒng)地建立起來的共識聲明，指定用于協(xié)助臨床決定，通常聚焦 在診斷和治療(美國外科醫(yī)生學(xué)院的創(chuàng)傷效果改善委員會(huì)，2002)。指南通常在 本質(zhì)上是全面的，經(jīng)常通過證據(jù)量進(jìn)行評估。指南通常由外科，創(chuàng)傷和病危護(hù)理 的社會(huì)團(tuán)體以教育和傳播恰當(dāng)護(hù)理主題知識的目的來建立。公開實(shí)行的指南提供 了以事實(shí)為基礎(chǔ)的文件，以此可建立特定公共機(jī)構(gòu)的路徑和醫(yī)療方案。Pathways and protocols expand on practice guidelines

45、 and are used as bedside instruments to influence care. The goal of both pathways and protocols is to decrease treatment variation in clinical management. Protocols are often institution-specific and consist of a step-by-step delineation of procedures for solving a problem or accomplishing a desired

46、 outcome. Protocols are often displayed in an algorithm format. While a pathway implies continuous data collection and monitoring, protocols may or may not include a continuous monitoring and data-evaluation component. An example of a protocol specific to trauma would be a “massive transfusion proto

47、col. In order to decrease the variability in the ratio of red blood cells transfused to the volume of clotting factors transfused, a massive transfusion protocol can be designed on the basis of existing data regarding best practices and used as a bedside tool to guide blood product administration in

48、 haemorrhaging patients.作為對診療指南的補(bǔ)充，路徑和醫(yī)療方案被用作影響護(hù)理的臨床工具。路徑和醫(yī) 療方案的共同目標(biāo)是減少臨床管理中的組間變異。醫(yī)療方案經(jīng)常是特定的社會(huì)機(jī) 構(gòu)，由解決問題或達(dá)到目標(biāo)所需的按部就班的程序組成的。方案通常是以文件格 式的形式呈現(xiàn)的。當(dāng)路徑包含連續(xù)的數(shù)據(jù)收集和追蹤，方案可以包含也可不包含 連續(xù)的追蹤和數(shù)據(jù)評估部分。具體的創(chuàng)傷醫(yī)療方案實(shí)例就是“大出血醫(yī)療方案”。 為了降低輸血中血紅細(xì)胞凝結(jié)的比例變異，大出血醫(yī)療方案可根據(jù)現(xiàn)存最佳診療 效果來制定，并可作為指導(dǎo)出血病人的血液制品管理的臨床工具。Several examples of institutin

49、g or changing institutional protocols as a means of correcting problems identified by QI programmes are given below in the section “Closing the loop”.下面“閉環(huán)”這一章中給出了幾個(gè)例子是關(guān)于制定或改變常用醫(yī)療方案，作為質(zhì) 量改進(jìn)項(xiàng)目鑒定的修正問題的方法。Targeted education目標(biāo)教育Educational opportunities include existing methods such as daily ward教育機(jī)會(huì)包括現(xiàn)

50、有的方法如每天日報(bào)。 rounds, departmental grand rounds, regularly scheduled conferences, and case presentations. Other less routine but excellent educational opportunities include periodic journal clubs to highlight and openly discuss influential and controversial publications, as well as focused reading grou

51、ps on specific topics of interest. Alternative educational options include newsletters, posters and videos from professional societies and health ministries. Many of these types of educational materials do not require the physical presence of a practitioner in a scheduled meeting and therefore can b

52、e accessed by the clinician when convenient.演講，部門大型演講，定期安排的會(huì)議和病情介紹。其他非常規(guī)的但絕佳的教育 機(jī)會(huì)包括期刊俱樂部，可重點(diǎn)公開討論有影響和有爭議的發(fā)表作品，也包括對特 定主題感興趣的集中閱讀人群?？蛇x擇的教育方式包括來自專業(yè)協(xié)會(huì)和健康部門 的新聞通訊，海報(bào)和視頻。許多這種教育素材不需要醫(yī)師出現(xiàn)在定點(diǎn)會(huì)議上，因 此可在臨床醫(yī)生方便時(shí)進(jìn)行。A typical example of a targeted educational effort that might be identified by the QI process follo

53、ws. By evaluating recent trauma deaths, the QI process may reveal that a problem exists with regard to patients with pelvic fractures. A number of patient deaths secondary to pelvic fractures and associated pelvic haemorrhage might be discovered as part of the QI technique of preventable death panel

54、 reviews. So if the QI process has now identified a problem, what is a possible corrective strategy to fix this problem? A method that potentially decreases mortality secondary to haemorrhage from pelvic fracture is early external reduction and stabilization of the fracture in the emergency departme

55、nt. A simple, easily available and cost-effective method for initial pelvic stabilization is pelvic “binding” or sheeting”. Although, the concept of pelvic sheeting is relatively simple and cheap, the actual specifics of where and how to apply the binding sheet effectively can best be relayed to cli

56、nicians through a targeted teaching session. The targeted educational session should include direct hands-on practice of the technical aspects of how to apply pelvic binding in patients with a pelvic fracture. Additionally, an essential component of this type of targeted educational experience is a

57、thorough discussion, which should include a question-and-answer component on the indications, and explanation of the small tricks that make application of the binding sheet more effective in optimally reducing fracture, the length of the binding, and the advantages and disadvantages of using the tec

58、hnique of sheeting in patients with pelvic fractures.接著是可被質(zhì)量改進(jìn)程序鑒定的目標(biāo)教育成就的典型例子。通過評估近期的創(chuàng)傷 死亡人口，質(zhì)量改進(jìn)程序可顯示骨盤裂病人存在著一個(gè)問題。作為預(yù)防死亡專題 小組審查的質(zhì)量改進(jìn)技術(shù)的一部分，可以發(fā)現(xiàn)許多病人死于繼發(fā)骨盤裂和并發(fā)骨 盆大出血。因此如果質(zhì)量改進(jìn)程序現(xiàn)在確定了一個(gè)問題，解決問題的可能的修正 策略是什么？可能減少骨盤裂大出血繼發(fā)死亡率的方法是在急救處盡早降低外 部風(fēng)險(xiǎn)并穩(wěn)定骨盤裂。一個(gè)初始穩(wěn)定骨裂的簡單、易于操作并且價(jià)廉的方法是骨 盤固定或護(hù)板。盡管骨盤護(hù)板的想法相對簡單和廉價(jià)，但是在哪和怎樣有

59、效實(shí)施 固定的細(xì)節(jié)，能夠通過目標(biāo)教育課程很好的傳達(dá)給臨床醫(yī)生。目標(biāo)教育課程應(yīng)包 括直接動(dòng)手實(shí)踐如何對骨裂病人實(shí)施骨盤綁定的技術(shù)方面。另外這類目標(biāo)教育經(jīng) 歷的一個(gè)重要部分是進(jìn)行徹底討論，包括關(guān)于指導(dǎo)的問答部分和解釋一些小技 巧，如何使捆綁條更有效降低骨裂、捆綁的長度、對骨盤裂病人使用護(hù)板技術(shù)的 優(yōu)勢和劣勢。It is often useful to hold joint educational conferences with other services that are closely involved in caring for trauma patients. Regularly sch

60、eduled combined teaching conferences can discuss evidence-based guidelines, difficult cases, and other relevant topics. Such teaching conferences can involve two or more services such as general surgery, emergency medicine, anaesthesiology, orthopaedics, neurosurgery, and others. These conferences c