質評価としての同僚評価―外傷の救急医療の質の研究委員会EMSQの方法―

Abstract

Education, resident training, guidelines, and evaluation are necessary to improve health care quality. Changing the resident system, re-organizing medical associations and Evidenced-Based Medicine (EBM) are becoming popular, and clinical practice using guidelines has been stressed in recent years in Japan. However, clinical evaluation is generally not so popular, except within internal conferences, and during short discussions at medical societies, although evaluation of the hospital services is on going by the Japanese Council for Quality Health Care (JCQHC). In contrast, the Joint Commission on Healthcare Accreditation Organization (JCAHO) is generally used for evaluation of hospitals in the US. The TRISS (Trauma and Injury Severity Score) method has offered a standardized approach to the evaluation of the outcome of trauma care. All trauma cases admitted to emergency centers in Japan were reviewed using the TRISS methodology in 2001 to assess preventable trauma death (PTD). There are big discrepancies regarding PTD among hospitals. The Emergency Medicine Study Group for Quality (EMSQ), organized by 14 emergency centers in the Kanto area, has developed a peer review (PR) system using explicit standards together with the TRISS methodology, in order to promote accuracy in the evaluation of PTD. Definitions of trauma, PTD, and a set of standards consisting of 20 items for determining PTD, were proposed. The optimal quality level of medical care for the patients was the criterion against which decisions regarding PTD were made. All death cases whose probability of survival (Ps) value exceeded 50% were reviewed using a PR method based on explicit standards. The PR process found that only 11.2% of all deaths were preventable, although 25.3% were considered preventable by the TRISS method. The PR process, using explicit standards, provided an excellent method of evaluation of PTD. The PR process also serves an educational purpose in improving the quality of care in emergency trauma cases. PR, by applying uniform standards at the optimal level of quality for the patients, offers not only more precise assessment, but also a means of case identification for quality assurance review on a local basis. Outcome reviews will offer the opportunity to assess comparability with national standards and norms. Trauma registry and evaluation are recommended for all emergency centers in Japan. These evaluation processes may be useful for systematic improvement of the emergency medical field.