Der Unfallchirurg
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There are several scores available for assessment of disability and handicap in rehabilitation. In primary treatment most interest has so far been given to the assessment of neurological recovery after operative decompression of the spinal cord. ⋯ Scores should take account of this. The neurological classification of ASIA, IMSOP and DMGP seems to be suitable for assessment of the course through-out the rehabilitation period.
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Among the more than 50 scoring systems available for quantitative evaluation of injury severity, only a few have proved effective in clinical practice. In particular, the Revised Trauma Score (RTS), referring to physiological variables, has proved effective in preclinical use and otherwise, the Injury Severity Score (ISS), referring to anatomical data. There is a tendency in the development of new scoring systems to aim at higher predictive accuracy, forfeiting practicability. ⋯ When the scoring systems currently available are applied their specific deficiencies and limited evidence must be borne in mind. Nevertheless, they are an important scientific instrument for comparative examinations, and indispensable for quality assurance and economic analyses. To improve the predictive accuracy, biochemical parameters and chronic diseases should be considered, in addition to existing scores.
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Numerous scoring systems are available for various particular situations. Some clinicians consider scores as mandatory for daily clinical decision making, while others see them only as additional work with no proven benefit except for scientific aspects. Although scoring systems have their limitations, they can also be of value. ⋯ The specific aims of different scoring systems are discussed and evaluated for the areas of disease classification, monitoring of individual patients and applications to individual decisions, quality assurance (comparison of patient groups and therapies), economic evaluation and global triage decisions. Despite the additional workload it is concluded that scoring systems are of proven benefit for classification of the degree of severity of a disease process, quality assurance, and better assessment of costs containment. These instruments will become increasingly important in our current discussion on changes in health care systems.
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A variety of different scoring systems are in current use, with an increasing impact on intensive care treatment. Originally these scoring systems were applied to evaluate objective grading and to estimate survival and mortality. More recently, other potential applications have been investigated. ⋯ Although desirable, individual patient prediction is therefore not allowed, and therapeutic strategies and therapy evaluation based on scoring systems cannot be implemented, or only in a limited way. For daily use in individual patient evaluation--monitoring, therapy response, prognosis--biochemical monitoring is still of primary importance. Scoring systems have now found a useful application as a supplement, rather than a rival, to clinical patient evaluation.
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In January 1992 the German Society of Trauma Surgery founded the working group "Scoring" with the aim of developing guidelines for a standardized use of scoring systems in severely injured patients. The study group developed the "Trauma Register" for prospective data collection in severely injured patients, from the scene of the accident up to discharge from hospital. The register contains routinely available anatomical and physiological variables, diagnostic and therapeutic interventions, and any complications. ⋯ Trauma centres can compare their own performance against given standards (quality control). If there are deviations from the norms the reasons have to be identified and necessary countermeasures should be implemented (quality assurance). The register has been tested in a feasibility phase in six German trauma centres and will hopefully have an impact comparable to that of the Major Trauma Outcome Study (MTOS) in the USA.