untitled

REVIEW ARTICLE 외상팀의구성과역할 고려대학교의과대학외과학교실 김남렬 Organization and Roles of the Trauma Team Namryeol Kim, M.D. Department of Surgery, Korea University College of Medicine, Seoul, Korea Correspondence to: Namryeol Kim, M.D. Department of Surgery, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea Tel: +82-2-2626-1147 Fax: +82-2-2626-1148 E-mail: drknr304@outlook.com In a narrow sense, the trauma team is intra-hospital organization that perform the initial assessment and resuscitation for the victims. Cooperation with the administrative and governance body of the hospital is essential for the function as a trauma center. The hospital could be as a core of the trauma care system with this support. Essential to this core position is a hospital trauma program that regulates and supports the trauma team activities. This trauma program consists of the hospital governance, administration, the trauma team and leader, trauma program manager, the registrar and the multidisciplinary committee of the performance improvement program. The essential elements of the trauma team include a trauma surgeon, an emergency physician, emergency department nurses, a laboratory and radiology technician, an anesthesiologist and a scribe. The team leader should be a trauma surgeon and coordinate the multidisciplinary professions in the team during the entire trauma care process. Clear criteria for the trauma team activation should be defined in advance. The composition of the team and the activation criteria may vary with the hospital capacity, the severity of injury, and the level of activation. The tiered criteria are based on clinical information from the field: physiologic and anatomic conditions and mechanism of injury and are recommended. The multidisciplinary committee for the performance improvement should monitor and assess trauma program outcomes. These activities will lead to trauma care improvements. (J Acute Care Surg 2016;6:46-53) Key Words: Trauma centers, Triage, Resuscitation Received September 15, 2015, Revised February 29, 2016, Accepted March 10, 2016 Copyright 2016 by Korean Society of Acute Care Surgery cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN 2288-5862(Print), ISSN 2288-9582(Online) https://doi.org/10.17479/jacs.2016.6.2.46 서론 서구의많은국가에서와같이한국에서도외상은 10세에서 49세에이르는활동기연령군에서가장흔한사망원인이다 [1]. 이런높은외상환자의발생률과그로인한사망률을낮추려는노력으로 1) 사고발생지점, 즉병원전단계부터병원단계또는그이후의모든치료과정에서외상치료의원칙을정확히 적용하고, 2) 이러한원칙이모든의료현장에서적용되기위하여 Advanced Trauma Life Support 또는 Korean Trauma Assessment and Treatment로대표되는기본적인외상처치에대한교육을더욱폭넓게보급하며, 3) 사회전반에걸친외상사고발생을줄이기위한다양한예방활동을강화하고, 4) 지역및국가적외상체계를구축하며, 5) 이상의모든활동을뒷받침하는법제의마련등을들수있다. 일반적으로이상에서언급한바와같은 46 J Acute Care Surg Vol. 6 No. 2, October 2016

Namryeol Kim: Organization and Roles of the Trauma Team 사회전반의외상진료및예방을모두포함하는지역및국가전반의시설, 장비, 인력, 그의운영체계및그운영을뒷받침하는법제등을포괄하여외상체계라부르며, 이와같은사회조직전반의외상체계속에서실제로발생한외상환자의구조ㆍ구급및현장처치와병원으로의이송단계, 즉병원전단계와병원으로이송후환자의일차평가를통한초기소생술, 이차평가와그이후최종치료및재활치료를담당하는병원단계의조직과체계가실제적인외상체계의요체라할수있다. 또한병원전단계와병원단계의모든인적, 물적, 행정적구성요소로이루어진조직을넓은의미의외상팀이라한다. 이에대하여좁은의미의외상팀이라함은병원단계에서의외상환자에대한최초평가와다양한방법의소생술기를시행하는의료진으로구성된조직을이야기한다. 외상팀이효율적으로그기능과역할을하기위해서는진료과정에직접참여하는의료인력뿐아니라, 병원내의사결정기구와그결정과제반운영사항을시행하는행정조직간에긴밀한신뢰와협조, 그리고그병원이위치한지역기반의지지가필수적이다. 이렇게좁은의미의외상팀과그의활동을지지하는병원내의사결정기구와행정조직등을포괄하여병원내외상체계라하며, 이를기반으로비로소병원 ( 외상센터 ) 은외상체계의축으로자리할수있다. 병원내외상팀의적절하고효율적인활동의요체는외상팀의구성과그행동양식을규정하는적절한진료지침의수립이다. 병원내외상체계는원내외상프로그램이라는틀로정의되는데, 미국외과학회 [2] 가규정한그구성은 1) 병원내행정및의사결정조직, 2) 의료진, 3) 외상팀장, 4) 외상소생팀, 5) 외상프로그램매니저, 6) 외상데이터베이스관리자, 7) 외상진료질관리위원 ( 회 ) 등을그기본골격으로하고있고, 이중외상소생팀이앞에서언급한좁은의미의외상팀이다. 저자는원내외상체계의중심적역할을하여최종적으로는사회나국가외상체계의요체인원내외상팀의목적과필요성, 구성과활동방침에대하여고찰하고자한다. 본론 외상팀의구성의필요성과목적다발성중증외상환자의치료는그원칙과특성상관련된다양한분야의의료자원이거의동시에신속하게투입되어야하는수평적이며다학제적인접근방식을취해야한다. 이런치료적원칙과특성을만족시키기위해서는환자의도착또는그 이전시점부터환자의상태에대한정보가관련부서와인력에게동시전파되고인지되어치료에필요한분야에개별적인접촉과중복적인상황의전파로인한불필요한시간의낭비와그로인한치료의지연이없어야한다. 중증외상환자치료과정에관여하는의료진에의한수평적치료접근방식은소생이후단계에서도적용되어외상팀리더를중심으로각분야의의사들과환자의소생단계이후의치료방침을결정하는과정에서도지속적으로유지되는것이바람직하다. 또한이러한형태의일련의치료과정에서직접환자를진료하는의료부서뿐아니라모든진행단계에관여하는행정및지원부서또는인력으로동시다발적인정보의전파와공유가필요하다. 이러한정보의동시간전파를통해서행정및기타지원부분으로부터의시의적절한지원을이끌어낼수있기때문이다. 이렇듯이중증외상환자의병원내치료개시점에서부터효과적인치료를위하여필수적인체계인수평적다학제적치료접근방식의진료체계가가장원활하게수행되기위한방향으로원내외상팀이구성되고운영되어야한다. 이를통하여진단과동시에치료가진행될수있는중증외상환자의기본치료원칙이지켜질수있고, 가장빠르고효과적으로환자의소생술을진행하여안정상태를확보하고유지할수있다. 이것이원내외상팀의존재와그활동의목적이다. 병원내외상환자의초기치료및소생술을담당하는협의의외상팀은병원전단계를포함한전체사회또는지역의외상체계의한부분이며, 전체외상체계의질과수준을대표할수없다. 또한해당사회또는지역의외상체계의다른부분의수준과질에의한결과와분리하여협의의원내외상팀의중요성과외상팀을운영하는데에따른장점과결점을독립적으로파악하기힘들다. 그럼에도불구하고외상팀의설치와적절한운용이외상환자치료의질을높이는데상당히중요한부분임을알려주는많은보고들이있다 [3,4]. 외상팀의적절한운용이중증외상환자의주요사망시기에대한삼고분포중두번째고점, 즉초기원내치료시기에서의사망률을낮추는데필수적이라한다 [5]. 또한원내외상팀이이러한목적에부합하여적절히운영되는경우에는예방가능사망률을 42% 낮출수있다고한다 [6]. 이외에도외상팀의존재와적절한활동의유무에따른외상환자의치료과정의수행평가와치료성적에대한많은연구가있다. Petrie 등 [7] 은손상중증도 (injury severity score) 12점이상인증증외상환자의치료성적에대하여외상팀존재유무에따른치료결과에대한연구에서외상팀에의한초기치료군에서보다 www.jacs.or.kr 47

J Acute Care Surg Vol. 6, No. 2, Oct. 2016 좋은수행평가와생존율을보고하고있다. 또한레벨 I 외상센터에서외상팀의운용으로전체외상환자의사망률이 6.0% 에서 4.1% 로낮아졌으며, 이러한사망률감소효과는중증외상환자의경우에더뚜렷하여해당군에서의사망률이 30.2% 에서 22.0% 로낮아졌다고한다 [8]. Kim 등 [9] 은외상팀존재유무에따른골반골절환자의치료성적에관한연구에서외상팀이운용될때환자의응급실도착이후치료개시까지의소요시간, 지혈을위한처치시행까지소요시간, 수혈량이의미있게개선되었음을보고하였다. 소아중증외상환자를대상으로한 Vernon 등 [10] 의연구에서는응급실도착이후컴퓨터단층촬영시간, 수술실도착시간및응급실에머무는시간과같은치료수행의질적인지표도호전된다고하였고, 외상팀의운용이후소생치료의시간이감소하였다는보고 [11] 와외상환자의진단지연시간이 10분의 1로줄었다는보고 [12] (4.3% 에서 0.46%), 외상팀의운용으로응급실외상구역에서의체류시간을 33% 줄였다는보고 [13] 등은모두외상팀운용에의한외상환자의사망률이감소하는여러원인적요소중일부는외상환자치료과정의효율성과질이개선된결과임을함의한다하겠다. 외상팀의구성 Driscoll과 Vincent [14] 가외상환자의일차평가를완료하는소요시간이환자의최종치료성적과관련이있다고보고한바와같이외상환자의초기평가와소생술이빠르게이루어져야하며, 이를위하여수평적방식의치료접근이가능한외상팀이 Table 1. Trauma Resuscitation Team: high-level response to severely injured patient by Committee on Trauma, American College of Surgeons ㆍ General surgeon ㆍ Emergency physician ㆍ Surgical and emergency residents ㆍ Emergency department nurses ㆍ Laboratory technician ㆍ Radiology technologist ㆍ Critical care nurse ㆍ Anesthesiologist or certified registered nurse anesthetist ㆍ Operating room nurse ㆍ Security officers ㆍ Social worker ㆍ Scribe Data from the Committee on Trauma, American College of Surgeons (available from: https://www.facs.org/quality%20programs/ trauma/vrc/resources) [2]. 구성되고운용되어야한다. 최근에미국외과학회외상위원회에서간행된 Resources For Optimal Care of the Injured Patient 2014 에따르면협의의외상팀을외상소생팀 (Trauma Resuscitation Team) 이라칭하였으며, 그구성요소를 Table 1에서와같이정의하고있다 [2]. 영국의경우에서도원내외상팀은일반적으로외과, 응급의학과, 마취과의사와관련분야의간호사및기타지원부서의관련자들로구성된다고한다 [15]. 이두국가의외상팀에대한기본구성에대한내용에서와같이외상팀내에 24시간원내대기근무하는형태의외상외과의사와응급의학과의사의존재가외상환자의빠른소생술과응급수술까지시간을줄이는데필수적인요소라는인식은국가별로큰차이가없이대체로공통적인의견을가지고있는것같다. 이에저자가제안하는외상센터가운영되기위한최소규모의일반적인외상팀구성예는 Table 2에서와같다. 하지만외상팀의구성은정형화된것이아니라국가, 지역 또는기관의특성에따라다양한형태로존재한다. 즉, 해당외상센터가위치하는지역사회에서발생되는손상기전과빈도의차이, 병원전단계처치를위한지역기반서비스의질등과같은지역적여건, 외상센터의시설과인적규모와같은내부적여건과그필요성에따라적절하게수정변형된형태로존재할수있다. 이러한상황에따른외상소생팀의구성과규모의가변성은외상환자에대응하는외상팀활성화과정에서도적용되어외상환자의중증도와수등에따라서활성화되는외상팀의규모와대응내용이달리운영될수있다. Tsang 등 [16] 의외상초기치료의수행평가에대한연구의결과에서와같이외상팀리더의존재유무에따라초기외상치료의결과는크게달라질수있기때문에반드시사전에명시적으로지명된외상팀리더가필요하다. 외상팀리더는중증환자의초기소생술이외상환자의초기치료의기본원칙, 즉진단과 Table 2. Basic composition of high-level response Trauma Resuscitation Team Essential composition ㆍ Team leader=trauma surgeon ㆍ Emergency physician ㆍ General surgeon ㆍ Anesthesiologist ㆍ Orthopedic surgeon ㆍ Nurses ㆍ Radiology technician ㆍ Scribe Supporting composition ㆍ Neurosurgeon ㆍ Chest surgeon ㆍ Orthopedic surgeon ㆍ Plastic surgeon ㆍ Interventional radiologist ㆍ Blood bank/laboratory technician 48 www.jacs.or.kr

Namryeol Kim: Organization and Roles of the Trauma Team 치료가동시에빠르고원활하게진행되도록전체외상팀구성원의역할에대하여지시하고조정하여야한다. 이를위하여외상팀리더는외상소생술단계에서는직접적인치료술기를시행하지않으며전체적인진행상황을관망하고외상팀구성원의역할과행위에대한지시와그결과에대하여종합적으로분석하며판단하고추가적인검사계획을수립하며모든결과를종합하여최종치료계획을수립하는오케스트라에서의지휘자와같은역할을수행한다. 외상팀리더는보통외상외과의사, 일반외과의사가그역할을수행하나병원의규모와사정에따라상급외과전공의또는응급의학과의사가그역할을수행하기도한다. 비록외상팀리더가외과계의사와비외과계의사간의외상사망률의차이는보이지않는다는보고가있으나, 외상초기처치기간중에진단되지않은손상에대한연구 [17] 에서와같이효율적이고전문적인외상치료를위해서는외상외과의사가외상팀리더의역할을수행하는것이일반적으로제안된다. 이러한점을한국의실정에적용하여보면외상팀의리더로는외상환자처치에대한적절한교육을받고충분한진료경험과지식을갖추고있으며관련학회에서인증하는자격을갖춘외상외과의사가일반적으로고려되어야할것이다. 또한효과적인리더십이외상치료지침에서벗어나지않는보다양호한수행결과와의미있게연관되어있다는 Lubbert 등 [13] 의수행평가에대한비교연구나 Sakran 등 [18] 의후향적관찰연구와같이외상팀리더에게는충분한외상환자의치료경험과더불어전체팀원의수행과정을외상치료원칙에맞게이끌어가는지도자적인리더십이요구된다. 외상환자에대하여수행하는일차평가의최우선순위는환자의기도확보여부에대한판단과기도확보를위한신속한시술에있다. 그러므로중증외상환자의기도관리를위한전담의료진의역할에대하여반드시사전에임무가주어지고그담당자가정해져야한다. 이기도관리담당은외국의경우마취과의사가그역할을수행하도록지정또는권장하고있고병원의사정등에따라응급의학과의사, 외과의사또는중환자의학전문의가수행하기도한다. 이에대하여국내의상황에대하여는자세히조사보고된바가없으나, 현실적으로일부대형외상센터를제외하고는마취과의사가수행하는경우보다는응급의학과의사나외과의사가그역할을수행하는것으로추정된다. 정형외과와신경외과의경우외상팀의초기일차평가중이거나후의적절한시점에치료개입을하는데, 이는최초응급의학과의사의판단이나외상소생팀리더의결정에따른다. 즉정형외과 의사, 흉부외과의사또는신경외과의사의외상소생팀의포함여부또한그역할과수행능력에따른국가간지역간병원간차이에따라결정될수있다. 외상팀에참여하는간호사의수는대체로 2 3명정도가추천되고있다. 외상팀안에서간호사또는그와동등한자격과역할의의료인력의규모는외상팀활동상황에서그들의역할내용과규모에따라결정되어야하며, 초기소생단계에서그들에의하여수행되어야할모든업무가효과적이고원활하게이루어질충분한수의간호사의지원이필수적이다. 영상의학전문의의외상팀참여는신속한영상의학적진단검사의수행과외상팀리더의요청과같은특정상황에서 Focused Assessment with Sonography for Trauma의수행, 그리고영상의학적진단의결과물에대한정확한판독과분석을위하여고려될수있다. 다만외상팀에참여시기나방법은병원의인적구성과규모등에따라적절하게조절되고변경되어결정될수있다. 여기에추가적으로외과전공의와응급의학과전공의들이외상소생팀에포함될수있으며, 이경우에도그들에게정확한역할과수행범위, 책임등에대하여사전에미리지정되고훈련되어야한다. 중증외상환자의소생처치단계에서진행되는의료행위와과정, 그리고그결과를실시간의무기록으로작성하는전담기록요원이반드시필요하다. 이는충실한의무기록이갖는기본적인그필요성, 즉향후치료과정에서의근거중심적인자료, 진료의결과에대한평가의기본자료, 후향적연구를위한기본자료및법적인증거자료로의필요성이외에도교육적인자료로의가치를지닌다는점에서매우중요하다. 전담기록요원의운용에관한국내현황은조사보고된적이없으며현실적으로응급실또는중환자실의간호사가그역할을담당하고있다. 그러나이러한경우라하더라도기록을담당하는간호사는외상환자치료과정중에다른임상업무를수행하지않고의무기록작성에전담하도록사전에그역할을지정하고교육하는것이중요하다. 외상팀의구성에서주의할사항중에하나는과도한인력구성이다. 일개외상팀내에과도한인력이투입되는경우자칫팀내주의력의분산을가져오고팀리더의지시에효과적으로반응하기어려워오히려외상치료원칙을충실히따르는데방해요인으로작용할수도있기때문이다. 그러므로외상팀의규모와구성에있어서반드시수행되어야할역할에따른최적의인적구성이필수적으로요구된다. 많은의료기관에서단계별외상팀호출기준을적용하여수행하고있다. 이를위하여외상환자의손상기전, 예상되는손상정도, 생리적지표등에따라적절한 www.jacs.or.kr 49

J Acute Care Surg Vol. 6, No. 2, Oct. 2016 규모의외상팀이요구된다. 즉외상초기소생술단계에서의수행업무는외상환자의중증도에따라변경될수있으므로단계적외상팀호출기준에맞추어각단계에따라참여하는팀의규모또한유연하게변경운용되는것이바람직하다. 이런단계별외상팀의효과적인운영을위하여병원전단계현장구급요원으로부터의병원도착전환자에대한충분한사전정보공유가필수적이며외상팀의모든구성원은개별적으로중증외상환자치료과정에서의개인적인역할과위치를숙지하고있어야한다. 이러한전반적인상황에대하여사전에시나리오를통한외상팀의충분한역할훈련이충분히이루어져야한다. 기전과동반기저질환을바탕으로이루어진다. 미국외과학회외상위원회와영국외과학회가권고하는최소한의외상팀활성화기준은 Table 3과 4와같다. 특히미국외과학회외상위원회는외상팀활성화기준을단계적으로적용하고그에따른외상팀활성화의규모와내용또한단계적으로시행할것을권고하는데, 그내용은 Table 5의예시와같다. 이러한단계적인외상팀활성화에서최대활성화의기준은심박수, 호흡수및글래스고우혼수지수와같은생리적기준과골절부위와그정도등과같은해부학적기준에따르며제한적외상팀활성화를위한기준은외상의기전에의한분류를그기준으로한다. 외상팀의활성화 (trauma team activation) 외상팀은다학제적구성과수평적방식의운용으로빠른시간안에중증외상환자에대한의료자원을집중하도록하여빠른초기진단과소생술을시행하고최종치료방침결정과이후진료전개를통하여최종적으로외상환자의치료성적을향상시키는데그목적이있다. 이러한목적을더욱적극적으로달성하고효율적인외상팀의운용을위하여는외상팀의활성화를위한명확하게정의된기준, 즉외상팀활성화기준 (trauma team activation criteria) 이정해져야한다. 이기준은환자의손상정도와환자의수등에따라단계적으로설정되어야하는데, 기본적으로사고현장에서손상환자이송을위한환자분류지침의연장선에서정해지며이의신속하고명확한적용을위하여중요한기준이되는몇가지생리학적지표와환자상태및손상기전등현장에서습득가능한중요정보는환자의병원도착이전에통고를받는것이이상적이다. 이렇게환자도착전에공유된정보로환자의손상정도를미리예측할수있으며외상팀활성화기준으로사용할수있다. 외상팀활성화기준은환자의손상정도를나타내는지표, 즉생리적기준, 해부학적기준및손상 Table 4. Criteria for activating the trauma team by The Royal College of Surgeons of England ㆍ Airway compromise ㆍ Signs of pneumothorax ㆍ SpO 2 <90% ㆍ Pulse >120 times/min or SBP <90 mmhg in adults ㆍ Unconsciousness >5 minutes ㆍ Incident with five or more casualties ㆍ Incident involving fatality ㆍ High-speed motor vehicle crash ㆍ Where the patient has ejected from a vehicle ㆍ Knife wound above the waist ㆍ Any gunshot wound ㆍ Fall from >8 m ㆍ A child with altered consciousness, capillary refill >3 seconds Pulse >130 times/min ㆍ A child pedestrian or cyclist hit by a vehicle Data from The Royal College of Surgeons of England (available from: https://www.rcseng.ac.uk/publications/docs/severely_injured. html) [15]. SpO 2: peripheral capillary oxygen saturation, SBP: systolic blood pressure. Table 3. Minimum criteria for full trauma team activation by American College of Surgeons ㆍ SBP <90 mmhg at any time in adult/and age-specific hypotension in children ㆍ GSW to the neck, chest, or abdomen or extremities proximal to the elbow/knee ㆍ GCS score <9 with mechanism attributed to trauma ㆍ Transfer patients from other hospitals receiving blood to maintain vital signs ㆍ Intubated patients transferred from the scene, or ㆍ Patients who have respiratory compromise or are in need of an emergent airway includes intubated patients who are transferred from another facility with ongoing respiratory compromise ㆍ Emergency physician discretion Data from the Committee on Trauma, American College of Surgeons (available from: https://www.facs.org/quality%20programs/ trauma/vrc/resources) [2]. SBP: systolic blood pressure, GSW: gunshot wounds, GCS: Glasgow coma scale. 50 www.jacs.or.kr

Namryeol Kim: Organization and Roles of the Trauma Team Table 5. An example of tiered trauma team activation criteria Full trauma team criteria Physiologic ㆍ Unstable to adequately ventilate/intubated or assisted ventilation ㆍ Respiratory rate <10 times/min or >29 times/min ㆍ Any sign of respiratory insufficiency ㆍ SBP <90 mmhg or abnormal low BP for age ㆍ GCS motor score <6, GCS <14 ㆍ Deterioration of previously stable patient ㆍ Transfers requiring blood transfusion Anatomic ㆍ Penetrating injuries to the head, neck torso, or extremities proximal to the elbow/knee joint ㆍ Open or depressed skull fracture ㆍ Paralysis or suspected spinal cord injury ㆍ Flail chest ㆍ Unstable pelvic fracture ㆍ Amputation proximal to the wrist or ankle ㆍ Two or more proximal long bone fracture ㆍ Crushed, degloved or mangled extremity Limited trauma team criteria (mechanism of injury) ㆍ Falls: adult >6 m, child: >3 m or 3 height ㆍ High risk auto crash with - Intrusion >30 cm - Ejection from automobile - Death in same passenger ㆍ Motorcycle crash >30 km/h ㆍ Auto vs. pedestrian/cyclist thrown, run over, or with significant impact (>30 km/h) ㆍ High energy electrical injury ㆍ Second or third degree burns >10% TBSA and/or inhalation injury ㆍ Suspicion of hypothermia, drowning, hanging ㆍ Blunt abdominal injury with firm or distended abdomen or with seat belt sign Data from the Committee on Trauma, American College of Surgeons (available from: https://www.facs.org/quality%20programs/ trauma/vrc/resources) [2]. SBP: systolic blood pressure, BP: blood pressure, GCS: Glasgow coma scale, TBSA: total body surface area. 이러한기준으로외상팀활성화를할때 undertriage와 overtriage의비율을고려해야하는데각항목에서지나치게높은비율은각각외상환자의진단과치료지연으로인한치료결과의악화나지나친인적, 물적의료자원소진과의료진피로축적등의문제를야기한다. 그러므로각각의비율에대하여각단위병원이나센터에서후향적으로적절한평가가이루어져야하며그결과는외상팀운용을포함한전체외상체계의질적관리과정에반영하여필요한경우기존의기준을변경하는노력이있어야한다. 미국외상학회는이와같은기준에의한외상팀활성화과정에서의 overtriage, undertriage의적정비율을고시하고있지는않고, 사고현장에서외상센터로이송에대한적절한 overtriage와 undertriage 비율을각각 25 35% 와 5% 로제시하였다. Dehli 등 [19] 은해부생리학적지표와손상기전을기준으로한외상팀활성화기준의비교에서손상기전을기준으로하였을때더많은 overtriage의경우가발생하며전원되어온경우나두경부손상의경우에서 undertriage의발생이많다고하였다. Krieger 등 [20] 은소아외상환자에대한외상팀활성화기준을해부학적, 생리학적기준으로하는것이손상기전에의한기준보다충분히납득할만한정도의 undertriage 비율을보이는동시에더높은정확도를보여해부학적, 생리학적기준을사용할것을제안하였 고, Lehmann 등 [21] 은여러가지분화된기준에따른단계적활성화의경우 1% 정도의 undertriage 비율을보이나그에반하여지나치게높은 overtriage 를보여이에회귀분석을통하여선택적으로정한단순기준에의한활성화를제안하였다. 반면 Davis 등 [22] 은유사한지표로이루어진활성화기준을적용하여두단계로외상팀활성화를시행한결과 undertriage 비율과 overtriage 비율이각각 3% 와 27% 로보고하였다. 이처럼대부분의국가나의료기관에서미국외과학회가제안하는기준또는그와유사한변형된기준을적용하는것으로보이나모든지표들에대하여국가간지역간의료기관사이에의견의일치를보이지는못하며, 그효율성과정확도등에대하여다양한의견이존재한다. 그러므로국내의료기관에서도지역외상체계의상황과각외상센터가속한의료기관의규모, 인적물적자원의상황등을바탕으로가장적절한외상팀활성화의기준을마련해야할것이다. 최고수준의외상팀활성화상황에서의반응시간은미국의경우레벨 I 또는 II 외상센터에서는환자도착후 15분이내, 그이하규모의외상센터에서는 30분이내정도로요구되고있다. 하지만대부분의경우현장의구급요원으로부터자세한손상정보가제공되지않거나불고지상태에서환자의병원이송이이루어져사전인지된정보를바탕으로환자도착이전에외상팀 www.jacs.or.kr 51

J Acute Care Surg Vol. 6, No. 2, Oct. 2016 활성화가이루어지는경우가상대적으로적은우리나라의현실적상황을고려할때이러한기준이우리나라에서그대로적용되기에는제한이따른다. 병원내외상팀의운용뿐만아니라전체외상시스템의효율적인운용을위해서병원전단계의환자평가와초기처치는그대로병원단계의진료과정과유기적으로매끄럽게연결되어야하며, 이를위하여병원전단계현장환자분류기준과이송프로토콜이명확히설정되어시행되어야하고이러한기준들이병원단계의외상팀활성화기준과도연계되고부합해야한다. 또한병원전단계에서구조구급을담당하는조직으로부터의료기관으로의손상과환자에대한정확하고신속한정보전달이필수적이나현실적으로이러한점에서미흡한점이많은국내상황을고려할때이의개선을위하여사고현장즉, 병원전단계를포함한전반적인외상처치체계의법적행정적보완이요구된다. 결론 광의의원내외상프로그램은다학제적접근양식을기본으로하며, 기존의임상단위의체계를초월하여구성되며그리더의역할은외상외과의사가수행함이일반적이다. 여기에는병원의행정지원, 의사결정기구의참여가반드시필요하며모든구성과역할은사전에명확히규정되어야한다. 병원내외상팀구성과운용은손상환자에대한수평적이며다학제적접근을통한치료의질을극대화하기위한외상진료모델이다. 또한최초활성화부터진료종료까지전과정에걸쳐모든외상팀구성원들의협동과이해가반드시필요한팀단위의접근방식이다. 이러한협동과조화로운활동을위하여명확하게사전에규정된활동개시와진행에관한지침이마련되고수행되어야한다. 또한외상팀내의인적구성원은해당전담분야와더불어외상진료분야에대하여충분한경험과자격을갖추어야하며이를위하여지속적으로교육훈련되어야한다. 병원전단계에서활동하는조직과원활한연계도성공적인외상팀활동에필수적인요소이며, 특히우리나라의경우이부분에서상대적으로취약하므로충분한보완이필요할것이다. 외상팀의조직과운용에있어서어떠한고정된규칙이나기준은없다. 모든의료기관은언제라도외상환자를접하게될가능성이있으므로각지역과기관의실정에맞는형태와규모의외상팀을구성해야하며, 적정한질관리를통하여그기준을끊임없이개선하는노력이필요하다. Conflicts of Interest No potential conflict of interest relevant to this article was reported. References 1. KOSTAT. Causes of Death Statistics in 2013 [Internet]. Daejeon: KOSTAT; c2014 [cited 2015 Jul 28]. Available from: http://kostat.go.kr/portal/korea/kor_nw/3/index.board? bmode=read&bseq=&aseq=330183. 2. Committee on Trauma, American College of Surgeons. Resources for optimal care of the injured patient [Internet]. Chicago: American College of Surgeons; 2014 [cited 2015 Sep 14]. Available from: https://www.facs.org/quality%20programs/ trauma/vrc/resources. 3. McDermott FT, Cordner SM. Victoria's trauma care system: national implications for quality improvement. Med J Aust 2008;189:540-2. 4. Barquist E, Pizzutiello M, Tian L, Cox C, Bessey PQ. Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes Region of New York State. J Trauma 2000;49:63-9; discussion 69-70. 5. Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P, Preston C, et al. Trauma deaths in a mature urban trauma system: is "trimodal" distribution a valid concept? J Am Coll Surg 2005;201:343-8. 6. West JG, Trunkey DD, Lim RC. Systems of trauma care. A study of two counties. Arch Surg 1979;114:455-60. 7. Petrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. Trauma and Injury Severity Score. J Trauma 1996;41:870-3. 8. Gerardo CJ, Glickman SW, Vaslef SN, Chandra A, Pietrobon R, Cairns CB. The rapid impact on mortality rates of a dedicated care team including trauma and emergency physicians at an academic medical center. J Emerg Med 2011;40:586-91. 9. Kim JW, Hong SK, Kyung KH, Choi JH, Kim JJ. Comparison of the mortality rate according to the presence of trauma team in hemodynamically unstable patients with pelvic ring injury. J Korean Orthop Assoc 2012;47:191-7. 10. Vernon DD, Furnival RA, Hansen KW, Diller EM, Bolte RG, Johnson DG, et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims. Pediatrics 1999;103:20-4. 11. Driscoll PA, Vincent CA. Organizing an efficient trauma team. Injury 1992;23:107-10. 12. Perno JF, Schunk JE, Hansen KW, Furnival RA. Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service. Pediatr Emerg Care 2005;21: 367-71. 13. Lubbert PH, Kaasschieter EG, Hoorntje LE, Leenen LP. Video registration of trauma team performance in the emer- 52 www.jacs.or.kr

Namryeol Kim: Organization and Roles of the Trauma Team gency department: the results of a 2-year analysis in a Level 1 trauma center. J Trauma 2009;67:1412-20. 14. Driscoll PA, Vincent CA. Variation in trauma resuscitation and its effect on patient outcome. Injury 1992;23:111-5. 15. The Royal College of Surgeons of England. Better care for the severely injured. London: The Royal College of Surgeons of England; 2000. 16. Tsang B, McKee J, Engels PT, Paton-Gay D, Widder SL. Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting. World J Emerg Surg 2013;8:39. 17. Leeper WR, Leeper TJ, Vogt KN, Charyk-Stewart T, Gray DK, Parry NG. The role of trauma team leaders in missed injuries: does specialty matter? J Trauma Acute Care Surg 2013;75:387-90. 18. Sakran JV, Finneman B, Maxwell C, Sonnad SS, Sarani B, Pascual J, et al. Trauma leadership: does perception drive reality? J Surg Educ 2012;69:236-40. 19. Dehli T, Fredriksen K, Osbakk SA, Bartnes K. Evaluation of a university hospital trauma team activation protocol. Scand J Trauma Resusc Emerg Med 2011;19:18. 20. Krieger AR, Wills HE, Green MC, Gleisner AL, Vane DW. Efficacy of anatomic and physiologic indicators versus mechanism of injury criteria for trauma activation in pediatric emergencies. J Trauma Acute Care Surg 2012;73:1471-7. 21. Lehmann RK, Arthurs ZM, Cuadrado DG, Casey LE, Beekley AC, Martin MJ. Trauma team activation: simplified criteria safely reduces overtriage. Am J Surg 2007;193:630-4; discussion 634-5. 22. Davis T, Dinh M, Roncal S, Byrne C, Petchell J, Leonard E, et al. Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital. Injury 2010;41:470-4. www.jacs.or.kr 53