Performance Evaluation of Emergency Medical Center 1998 2
Performance Evaluation of Emergency Medical Center. 1997 10 1997 12
,... W -. 35 1996 1 1 12 31 1 44,750 W- 35.., ICISS., 35 34%.,. - i -
, W - 8 100 8., 3, 3,,..,. : ICISS, SRR, W-,, - ii -
I. 1 II. 3 1. 3 2. 4 3. 5 1) T rauma and Injury Severity Score 5 2) ICD- 9 based Injury Severity Score 7 III. 9 1. 9 2. 10 1) 10 2) 13 IV. 14 1. 14 2. 16 3. 17 V. 20 1. 20 2. 21 3. 23 - iii -
V I. 25 V II. 27. SRR 30 A bs tract 44 - iv -
1. Revised T rauma Score 4 2. T RISS regression coefficients 6 3. 9 4. 10 5. 16 6. 18 7. W - 20 - v -
1. 20 - vi -
I. 3, 45 1 (, 1997). (potential life year lost) 1, 45.3% (, 1996).., (preventable death). T rauma and Injury Severity Score (T RISS) A Severity Characterization of T rauma (ASCOT ) 50%, 50% (Sampalis, 1995). 40% T RISS ASCOT 50% (, 1994;, 1996).. T RISS ASCOT, - 1 -
.. International Classification based Injury Severity Score(ICISS),,. - 2 -
II.,,,. (Champion, 1995).,. (Physiologic measure) (measure of anatomic demage), (biochemical measure). 1. (Phy s iolog ic meas ure) Glasgow Coma Scale(GCS),, GCS Revised T rauma Score(RT S), circulation, respiration, abdominal/thoracic, motor, speech(crams) scale Acute Physiologic and Chronic Health Evaluation(APACHE). RT S, T rauma Score. RT S. RT S GCS,. RT S. - 3 -
, T rauma Score. Injury Severity Score(ISS) RT S, (Ohsfeldt, 1996). RTS = 0.9368(GCS ) + 0.7326(S BP ) + 0.2908(RR) 1. Revised T rauma Score Coded Value GCS SBP RR 4 13-15 >89 10-29 3 9-12 76-89 >29 2 6-8 50-75 6-9 1 4-5 1-49 1-5 0 3 0 0 2. (meas ure of anatomic demag e) (International Classification of Disease; ICD) 1950 Abbreviated Injury Scale(AIS), AIS Injury Severity Score(ISS), Anatomic Profile. ISS. AIS. ISS AIS 3. - 4 -
ISS 16. IS S = AIS (1)2 + AIS (2)2 + AIS (3)2 ISS AIS 3 (Copes, 1988). ISS 16. Major T rauma Outcome Study(MT OS), 17.2% 0% (Champion, 1995). ISS (Rutledge, 1996). 3. ( Ev aluation of T rauma Outcome) 1) T rauma and Injury Severity Score(T RISS). T RISS A Severity Characterization of T rauma(ascot ). 1982 1989 160 17 MT OS.,, - 5 -
. T RISS. 1981 T RISS. T RISS (blunt injury) (penetrating injury), ISS RT S, (logistic regression model).,, (disparity),. MT OS 64.3%, 99.1%, 0.614, 84.2%, 98.7%, 0.810 (Champion, 1990). T RISS. 55, 55 AGE=1, 55 AGE=0. (norm) MT OS 2. P s = 1/(1+e -b) b = b0 + b1(rts ) + b2(is S ) + b3(age) 2. T RISS regress ion coefficients b0 b1 b2 b3 Blunt - 1.2470 0.9544-0.0768-1.9052 Penetrating - 0.6029 1.1430-0.1516-2.6676-6 -
2) ICD- 9 bas ed Injury Severity Score(ICISS) T RISS ASCOT AIS,., (McDermott, 1994; Osler, 1995).. 50 24, 20%,, (McDermott, 1994; Shapiro, 1994). (discharge abstract) ICD- 9 (MacKenzie, 1989; Osler, 1995; Rutledge, 1995; Rutledge, 1993). Osler (1995) ICISS. ICISS (survival risk ratio ; SRR). 0 1,,. Osler (1995) ICISS ISS, ICISS,, RT S T RISS. ICISS. ICISS - 7 -
, ISS 3., ISS. (Osler, 1995). - 8 -
III. 1. 1996, 100 40 5. 3, 4. 3. (%) 22,160 900 30 12 40 4,329 210 7 4 57 3,910 180 6 1 17 1,770 60 2 1 50 2,229 120 4 1 25 2,759 150 5 3 60 3,808 240 8 3 38 3,052 150 5 3 60 1,060 90 3 1 33 1,450 60 2 1 50 2,344 120 4 1 25 2,306 270 9 1 11 3,012 240 8 3 38 2,483 150 5 0 0 679 60 2 0 0 57,351 3,000 100 35 35-9 -
4. 3 3 3 18 17 24,150 23,600 19 16 25,014 22,736 12 10 13 14,728 14,556 18,466 1996 1 1 1996 12 31 S T, 47,750,,, (10 ),. 2. 1) T RISS,. ICISS. ICISS (Survival Risk Ratio : SRR) - 10 -
SRR (ICD- 10 code) W-.. SRR 35 1996 1 1 12 31 47,750 (ICD- 10) (SRR). 1, 0, 47,750 0 1. 161,654 5,309. SRR. SRR = ( 0) ( ( 0) + ( 1) ). ICISS 5,309 SRR 47,750 ICISS. ICISS 3 10 (Osler, 1996) ICISS 10 1-11 -
10 SRR ICISS. ICISS = SRR_ 1 X SRR_ 2 X SRR_ 3 X SRR_ 4 X X SRR_ 10 SRR_ 1 = Probability of S urvival of Injury 1 SRR_ 2 = Probability of S urvival of Injury 2 SRR_ 10 = Probability of S urvival of injury 10. W-. W -. ICISS 0.5, 0.5 ' W-. W-. W = ( A - E ) N 100 A : E : N : - 12 -
W - 100 W- 3 100, 3. W- 0. 2).. McKenzie (1990) 0.9. = ICISS 0. 9 ICISS 0. 9 ICISS. (case- mix) 1. - 13 -
IV. 1. (W- ) 5. (W- ) ( ) ( ) ( ) W- (%) 1 916 887 882 0.55 3.2 2 311 308 299 2.89 1.0 3 824 802 814-1.46 2.7 4 1,080 1,048 1,065-1.57 3.0 5 1,044 1,030 1,032-0.19 1.3 6 1,385 1,334 1,286 3.47 3.7 7 1,565 1,522 1,530-0.51 2.7 8 884 828 797 3.51 6.3 9 975 945 941 0.41 3.1 10 1,606 1,581 1,583-0.12 1.6 11 2,359 2,272 2,267 0.21 3.7 12 1,778 1,725 1,734-0.51 3.0 13 993 983 992-0.91 1.0 14 990 964 976-1.21 2.6 15 1,724 1,705 1,701 0.23 1.1 16 1,530 1,523 1,490 2.16 0.5 17 806 789 786 0.37 2.1 18 1,062 1,017 1,035-1.69 4.2 19 1,658 1,624 1,634-0.60 2.1 20 1,164 1,143 1,150-0.60 1.8 21 217 216 211 2.30 0.5 22 2,243 2,177 2,205-1.25 2.9 23 2,191 2,094 2,181-3.97 4.4 24 303 288 297-2.97 5.0 25 2,500 2,458 2,450 0.32 1.7 26 2,522 2,428 2,380 1.90 3.7 27 1,844 1,788 1,805-0.92 3.0 28 745 734 723 1.48 1.5 29 1,796 1,758 1,755 0.17 2.1 30 1,348 1,327 1,341-1.04 1.6 31 1,040 1,026 1,030-0.38 1.3 32 1,237 1,216 1,228-0.97 1.7 33 2,076 2,035 2,074-1.88 2.0 34 1,929 1,912 1,920-0.41 0.9 35 1,105 1,085 1,082 0.27 1.8 47,750 46,572 46,676 2.47-14 -
5. 35 47,750 2.47% 0.5% 6.5%. 46,572 ICISS 0.5, 50% 46,676. 100 W-. W- 3.51, W - - 3.97 100, 8. - 15 -
2. ( ) 6. ( ) ICISS 0.9 ICISS 0.9 ( ) ( ) (%) 1 916 269 29 0.87 2 311 125 40 1.19 3 824 151 18 0.54 4 1,080 351 33 0.97 5 1,044 260 25 0.74 6 1,385 611 44 1.31 7 1,565 460 29 0.87 8 884 434 49 1.46 9 975 382 39 1.16 10 1,606 452 28 0.84 11 2,359 1,122 48 1.41 12 1,778 556 31 0.93 13 993 209 21 0.63 14 990 264 27 0.79 15 1,724 588 34 1.01 16 1,530 644 42 1.25 17 806 326 40 1.20 18 1,062 405 38 1.13 19 1,658 529 32 0.95 20 1,164 293 25 0.75 21 217 84 39 1.15 22 2,243 620 28 0.82 23 2,191 843 38 1.14 24 303 79 26 0.77 25 2,500 788 32 0.94 26 2,522 1,202 48 1.42 27 1,844 697 38 1.12 28 745 253 34 1.01 29 1,796 789 44 1.30 30 1,348 433 32 0.95 31 1,040 296 28 0.85 32 1,237 475 38 1.14 33 2,076 276 13 0.39 34 1,929 520 27 0.80 35 1,105 294 27 0.79 47,750 16,076 33-16 -
6. 35 47,750 ICISS 0.9, 10% 16,076 10% 13% 48%. (norm) 10% 33%. 1.46, 0.39 case- mix. 3. W - 35 1. 1 1 35 12 34%. 2 3 9%. 3-17 -
16 46%. 4 4 11%. 3, 6. 3, W-. 1. - 18 -
7. W- W- 3 3 3 18 17 1.103 0.963 0.273-0.462 19 16 1.044 0.923 0.359-0.610 12 10 13 1.025 0.930 1.001 0.556-0.140-0.631-19 -
V. 1... 100 40 5.. (ICD- 10). 10 2 3. ICISS 3 (Osler, 1996). 1996 1 1 1996-20 -
12 31.. 2.. ICISS W-. ICISS (Osler, 1996). ICISS ICD- 9 ICD- 10. ICD- 10 ICISS. (, 1997) ISS, T RISS ICS- 10 ICISS. SRR SRR. - 21 -
.. 5 ICISS. ICISS.. 5,309 Osler (1996).. MacKenzie (1990) ISS 13 16. 90-95% 90%. - 22 -
3. W- 35 35 1 12 34%. 1, 3., (American College of Surgeons, 1993). 100-150 4 100., 3 16 50% 8. W - 8 100 8. 4-23 -
. 45.3% 40.4%.... - 24 -
VI., 1996 1 1 1996 12 31 35 47,750.., ICISS., 35 34%.,., W - 8 100 8., 3, 3,,. - 25 -
.,. - 26 -
VII.,,,,,. ASCOT method. 1994; 5(2):233-239,,,,,. AVPU scale Glasgow Coma Scale. 1996; 7(1):59-63,.. 1996; 9(1):105-111,,, : ; T riage Score Modified T riage Score. 7(2): 171-178, 1996.. 1997.. 1996. ' 97. 1997 American College of Emergency Physicians. T rauma care systems quality improvem ent guidelines. Ann Emerg Med 1992, 21:736-739 American College of Surgeons. Resources for optimal care of the injured patients. American College of Surgeons. Chicago 1987. American College of Surgeons. Resources for optimal care of the injured patient. American College of Surgeons. Chicago 1993, pp.77-83 Ash AS, Schw artz M. Evaluating the performance of risk- adjusted methods: Dichotom ous measures. In Iezzoni LI. Risk adjus tment for measuring health care outcome. Ann Arbor, Michigan: Health Administration Press, 1994:313-346. Bruce DA, S chut L, Bruno LA. et al., Outcome follow ing s evere head injuries in children. J Neurosurgery 1978; 48:679-688. Bruns B. T rauma system quality assurance. In Sw or RA(ed.). Quality - 27 -
management in prehospital care. St. Louis: Mosby Lifeline, 1993:161-190. Champion HR, Copes WS, Sacco WJ, et al. T he Major T rauma Outcome Study: establishing national norms for trauma care. J T rauma 1990; 30(?):1156-?. Champion HR, Sacco W J, Copes W S. T rauma scoring. In Feliciano DV, Moore EE, Mattox KL. T rauma. 3rd ed. A ppleton & Lange, 1995 Chong KH; T rauma System in the USA. JKST 9(1): 112-118, 1996 Copes W S, Champion HR, Sacco W J, Law nick MM, Keast SL, Bain LW. T he Injury Severity Score Revisited. J T rauma 1988; 28(1):69-77 Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Eas taman AB, Virgilio RW, et al. Ananalysis of errors causing morbidity and mortality in trauma system: Aguide for quality improvement. J T rauma 1992; 32(5):660-666 Esposito T J, S anddal ND, Hansen JD, Reynolds S. Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J T rauma 1995; 39(5):955-962 Feliciano DV, Moore EE, Mattox KL. T rauma. 3rd ed. Appleton & Lange 1995, pp.53-65 Hoyt DB, Hollingsworth- Fridlunf P, Fortlage D, Davis JW, Mackersie RC. An evaluation of provider- related and disease- related morbidity in a level I university trauma service: Directions for quality improvement. J T rauma 1992; 33(4):586-601 Markle L, Cayten G, Byrne DW, Moy F, Murphy JG. Comparison betw een T RISS and ASCOT methods in controlling for injury severity. J T rauma 1992; 33(2):326-332 McDermott FT. T rauma audit and quality improvement. Aust N Z J - 28 -
Surg 1994; 64(3):147-154 MacKenzie EJ, S teinw achs DM, Shankar B. Clas sifying trauma severity on hospital discharge abstract. Med Care 1989; 27(4):412-422 MacKenzie EJ, S teinw achs DM, Ramzy AI. Evaluating performance of statew ide regionalized systems of trauma care. J T rauma 1990; 30(6):681-688 Ohsfeldt RL, Morrisey MA, Johnson V, T reat R. S implyfying the assessment odf rural emergency medical services trauma transport. Med Care 1996; 34(12):1180-1187. Os ler T, Rutledge R, Deis J, Bedrick E. ICIS S: An International Classification of Disease- 9 based injury severity score. J T rauma 1996; 41(3):380-388 Rutledge R, F akhry S, Baker C, Oller D. Injury severity grading in trauma patients: A simplified technique based upon ICD- 9 coding. J T rauma 1993; 35(4):497-507. Rutledge R. Injury severity and probability of survival assessment in trauma patients using a predictive hierarchical netw ork model derived from ICD- 9 code. J T rauma 1995; 38(4):590-601. Rutledge R. T he Injury Severity Score id unable to differentiate betw een poor care and severe injury. J T rauma 1996; 40(6):994-950. Sampalis JS, Lavoie A, Boukas S, T amin H, Nikolis A, Frechette P, et al. T rauma center designation: Initial impact on trauma- related mortality. J T rauma 1995; 39(2):232-239 Shapiro MJ, Cole KE Jr, Keegan M, Prasad CN, T hompson RJ. National survey of state trauma registry- 1992. J T rauma 1994; 37(5):835-840. - 29 -
. SRR 1) 1) 5,309 SRR 1 968-30 -
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Abs tract P erformance Eva lua tion of Emerge ncy Medical Ce nte r Chul- Hw an Kang, MD Department of Health Policy and Management, Seoul National University, College of Medicine. (Directed by Profess or and Chairm an Youngsoo Shin, MD. DrPH) T he study w as conducted to identify levels of performances in practices of emergency medical centers(emcs) in Korea, and to provide the information in development of the policy alternatives for enhancing the quality of services of EMCs and emergency care delivery system. T he tw o indicator for performance measurement of EMCs w ere developed. One is ' W - statistic' of the center; death rate calculated on the basis of International Classification based Injury Severity Score(ICISS). T he other is ' the degree of severity' of the center; w hich is defined as ratio of severe trauma patients of each emergency medical centers. 44,750 cases of trauma care w ere collected during the year of 1996, and used for development of perform ance measures in 35 EMCs in Korea. T he study results are summarized as follows. F irst, applying the new performance meas ures, 34% EMCs provided proper care in terms of level of case severity mix as w ell as quality of services. - 44 -
Second, the results show ed that ratio of severe trauma patients and degree of care quality in each emergency medical centers w ere highly related. T hird, a score difference of ' W - statistics' betw een the highest and the low est emergency medical center w as 8. T his means that number of death can differ 8 per 100 patients of the same degree severity treated in each emergency medical centers. Fourth, tertiary hospitals, university hospitals, and hospitals located in Seoul show higher severity patients and low er severity- adjusted death rate. T o conclude, the low er quality of care in most of emergency medical centers has been acted as a major cause of lifting- up the preventable death rate. T herefore, by adopting new performance measures, it is necessary to regularly monitor the emergency medical centers in national level, then the results can be used for the criteria for designation of emergency medical centers. Key W ords; ICISS, SRR, W- statistic, Performance Evaluation, Emergency Medical Center - 45 -