 Evidence Based Prehospital Medicine & the Need for Research:
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Articles of Interest:
- WHO Guidelines for Essential Trauma Care, Executive Summary: This page also holds options for a printable or a pdf version of this document (764kb)
- NHSTA's role in Research & Evaluation and EMS Agenda for the Future, Research & Implementation Guide
- Article: "EMS RESEARCH - Obstacles of the Past, Opportunities in the Present, Models for the Future" By Elizabeth A. Criss, RN, MEd; Prehospital Care Research Forum Reference
- "Controversies in Pre-hospital Care" - by Will Chapleau, EMT-P, RN, TNS, Chief, Chicago Heights Fire Department; Chairman, PHTLS and Executive Council, National Association of EMTs, Chicago Heights, IL, USA: Faculty Interview by Institute for Prehospital Medicine (you will need RealPlayer to access this interview)
- Anatomy and Physiology of Research-by William Raynovich, MPH, NREMT-P - Senior Program Manager, EMS Academy, University of New Mexico, Albuquerque, New Mexico, USA: Faculty Interview by Institute for Prehospital Medicine (you will need RealPlayer to access this interview)
- Ethical Issues in Research Involving Human Participants - U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, National Institutes of Health
- Cochrane Review EMS-related Abstracts
- The OPALS Study
- Trauma Study: Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome?(1).
- The Brain Trauma Foundation:
Guidelines to the PreHospital Management of Traumatic Brain Injury
In-Hospital: Management and Prognosis of Severe Traumatic Brain Injury
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Relevant Trauma Research:
Title: Multicenter Prospective Validation of Prehospital Clinical Spinal Clearance Criteria [Abstract]
Robert M. Domeier, MD; Robert A. Swor, DO; Rawden W. Evans, MD, PhD; J. Brian Hancock, MD; William Fales, MD; Jon Krohmer, MD; Shirley M. Frederiksen, RN, MS; Edgardo J. Rivera-Rivera, MD; M. Anthony Schork, PhD
Published by the Journal of Trauma, Injury, Infection and Critical Care
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Title: Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome?(1).
Authors: Peter Pons, Vincent Markovchick
Affiliation: Department of Emergency Medicine and Denver Paramedic Division, Denver Health Medical Center, Denver, Colorado, USA
Reference: J Emerg Med 2002 May 23(1):43
Emergency Medical Services (EMS) agencies are increasingly being held to an ambulance response time (RT) criterion of responding to a medical emergency within 8 min for at least 90% of calls. This recommendation resulted from one study of outcome after nontraumatic cardiac arrest and has never been studied for any other emergency. This retrospective study evaluates the effect of exceeding the 8 min RT guideline on patient survival for victims of traumatic injury treated by an urban paramedic ambulance EMS system and transported to a single Level I trauma center. Of 3576 patients identified by the hospital trauma registry, 3490 (97.6%) had complete records available. Patients were grouped according to ambulance RT: </= 8 min (n = 2450) or > 8 min ( n = 1040). After controlling for other significant predictors, there was no difference in survival after traumatic injury when the 8 min ambulance RT criteria was exceeded (mortality odds ratio 0.81, 95% CI 0. 43-1.52). There was also no significant difference in survival when patients were stratified by injury severity score group. Exceeding the ambulance industry response time criterion of 8 min does not affect patient survival after traumatic injury.
Opinions of Trauma Practitioners Regarding Prehospital Interventions for Critically Injured Patients.
Journal of Trauma-Injury Infection & Critical Care. 58(3):509-517, March 2005.
Salomone, Jeffrey P.MD,FACS; Ustin, Jeffrey S. MD; McSwain, Norman E. Jr. MD, FACS; Feliciano, David V. MD, FACS
Links: Abstract (see also The Journal of Trauma-injury, Infection and Critical Care]
Abstract:
Background: Significant controversy surrounds the prehospital management of trauma patients.
Methods: A questionnaire describing clincial scenarios was mailed to random sample of 345 trauma practitioners.
Results: The 182 trauma practitioners (52.8%) who returned the surveys were predominantly general or trauma surgeons (83.5%) in academic or university practice (68.1%). For a patient with a severe traumatic brain injury, 84.5% of trauma practitioners recommended that emergency medical services personnel attempt intubation at least once when transport time was 20 to 40 minutes. For a patient with a gunshot wound to the epigastrium in decompensated shock, the majority of trauma practitioners believed that a relatively hypotensive state should be maintained, regardless of transport time. Trauma practitioners (52.2%) have recommended the use of the pneumatic antishock garment for transports of 20 to 40 minutes for patients with an unstable pelvic fracture and decompensated shock.
Conclusions: Most trauma practitioners believe that emergency medical services providers should attempt intubation for a patient with a severe traumatic brain injury, should treat decompensated shock in a patient with penetrating torso trauma but maintain the patient in a relatively hypotensive state, and should apply and inflate the pneumatic antishock garment for a suspected pelvic fracture accompanied by decompensated shock if the patient is 20 to 40 minutes from a trauma center. The recommendations of trauma practitioners regarding appropriate prehospital care are significantly influenced by the time required for transport to the trauma center.
(C) 2005 Lippincott Williams & Wilkins, Inc.
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Research Resources
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Research Grants
PHTLS Grants: PHTLS now offers research grants of up to $5,000.00 in an effort to promote innovative research in prehospital trauma care, and to improve the outcomes of trauma patients internationally. If you are interested in applying for this research grant, please download the following and submit as per instructions.
[PHTLS Grant Guidelines] [PHTLS Proposal Approval Form]
[NAEMT Grants] NAEMT offers Two Research Grants: In an ongoing effort to add to the growing body of knowledge about the science and practice of EMS and pre-hospital emergency medicine, NAEMT and its educational program, PHTLS, are offering two research grants for 2005. One grant will be given for a research project in the area of EMS workforce issues and the other grant will be given for a project in the area of prehospital trauma. These grants are being offered in cooperation with UCLA’s Pre-hospital Care Research Forum who will assist NAEMT and PHTLS in selecting and evaluating projects. The grants are for up to $5000.00 each and applications are due July 1, 2006. Contact Bob Loftus for further information (robert.loftus@mchsi.com)
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Research Search Engines
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PHTLS Program Study
Results from a study published in The Journal of Trauma: Injury, Infection, and Critical Care (view the abstract) indicate that learning trauma skills from the PHTLS course may be associated with improved mortality and morbidity rates.
The study indicates that "there was a further improvement in overall trauma patient mortality from 15.7% to 10.6% after the
PHTLS course?"
"We have demonstrated in this study that, after the introduction of the PHTLS program. There was better airway control,
C-spine control, splinting of fractures, hemorrhage control, and use of oxygen These factors may have accounted for patients
arriving at the hospital setting in a more optimal state. This status, in turn, should be expected to improve the chances of survival
of patients as well as decrease the morbidity rates after injuries."
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Citation 1.
Authors: Arreola-Risa C . Mock CN . Lojero-Wheatly L . De la Cruz O . Garcia C . Canavati-Ayub F . Jurkovich GJ .
Institution: Dr. C.N. Mock, Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104; United States.
E-Mail: cmock@u.washington.edu
Title: Low-cost improvements in prehospital trauma care in a Latin American city.
Source: Journal of Trauma-Injury Infection & Critical Care. Vol 48(1) (pp 119-124), 2000.
Abstract:
Objective: Prehospital care is a critical component of efforts to lower trauma mortality. In less-developed countries, scarce resources dictate that any improvements in prehospital care must be low in cost. In one Latin American city, recent efforts to improve prehospital care have included an increase in the number of sites of ambulance dispatch from two to four and introduction of the Prehospital Trauma Life Support ( PHTLS) course.
Methods: The effect of increased dispatch sites was evaluated by comparing response times before and after completion of the change. The effect of PHTLS was evaluated by comparing prehospital treatment for the 3 months before initiation of the course (n = 361 trauma patients) and the 6 months after (n = 505).
Results: Response time decreased from a mean of 15.5 +/- 5.1 minutes, when there were two sites of dispatch, to 9.5 +/- 2.7 minutes, when there were four sites. Prehospital trauma care improved after initiation of the PHTLS course. For all trauma patients, use of cervical immobilization increased from 39 to 67%. For patients in respiratory distress, there were increases in the use of oropharyngeal airways (16-39%), in the use of suction (10-38%), and in the administration of oxygen (64-87%). For hypotensive patients, there was an increase in use of largebore intravenous lines from 26 to 58%. The improved prehospital treatment did not increase the mean scene time (5.7 +/- 4.4 minutes before vs. 5.9 +/- 6.8 minutes after). The percent of patients transported who died in route decreased from 8.2% before the course to 4.7% after. These improvements required a minimal increase (16%) in the ambulance service budget.
Conclusion: Increase in sites of dispatch and increased training in the form of the PHTLS course improved the process of prehospital care in this Latin American city and resulted in a decrease in prehospital deaths. These improvements were low cost and should be considered for use in other less developed countries. [References: 20]
*COPYRIGHT ELSEVIER SCIENCE B.V. 2002 - ALL RIGHTS RESERVED*
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Citation 2.
Authors: Ali J . Adam R . Josa D . Pierre I . Bedsaysie H . West U . Winn J . Ali E . Haynes B .
Institution: Dr. J. Ali, Department of Surgery, University of Toronto, 100 College Street, Toronto, Ont. M5G 1L5; Canada.
Title: Effect of basic prehospital trauma life support program on cognitive and trauma management skills.
Source: World Journal of Surgery. Vol 22(12) (pp 1192-1196), 1998.
Abstract
We tested the effectiveness of a basic prehospital trauma life support (PHTLS ) program by assessing cognitive performance and trauma management skills among prehospital trauma personnel. Fourteen subjects who completed a standard PHTLS course (group I) were compared to a matched group not completing a PHTLS program (group II). Cognitive performance was assessed on 50-item multiple choice examinations, and trauma skills management was assessed with four simulated trauma patients. Pre- PHTLS multiple choice questionnaire scores were similar (45.8 +/- 9.4% vs. 48.8 +/- 8.9% for groups I and II, respectively), but the post-PHTLS scores were higher in group I (80.4 +/- 5.9%) than in group II (52.6 +/- 4.9%). Pre-PHTLS simulated trauma patient performance scores (standardized to a maximum total of 20 for each station) were similar at all four stations for both groups, ranging from 7.9 to 10.4. The post-PHTLS scores were statistically significantly higher at all four stations for group I (range 16.0-19.0) compared to those for group II (range 8.0-11.1). The overall mean pre-PHTLS score for all four stations was 8.3 +/- 2.1 for group I and 8.8 +/- 2.0 (NS) for group II; the group I post-PHTLS mean score for the four stations was 17.1 +/- 2.7 (p < 0.05) compared to 9.1 +/- 2.3 for group II. Pre-PHTLS Adherence to Priority scores on a scale of 1 to 7 were similar (1.1 +/- 0.9 for group I and 1.2 +/- 1.0 for group II). Post- PHTLS group I Priority scores increased to 5.9 +/- 1.1. Group II (1.1 +/- 1.0) did not improve their post-PHTLS scores. The pre- PHTLS Organized Approach scores in the simulated trauma patients on a scale of 1 to 5 were 2.1 +/- 1.0 for group I and 1.9 +/- 1.2 for group II (NS) compared to 4.2 +/- 0.9 (p < 0.05) in group I and 2.0 +/- 0.8 in group II after PHTLS. This study demonstrates improved cognitive and trauma management skills performance among prehospital paramedical personnel who complete the basic PHTLS program. [References: 14]
*COPYRIGHT ELSEVIER SCIENCE B.V. 2002 - ALL RIGHTS RESERVED*
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Citation 3.
Authors: Ali J . Adam RU . Gana TJ . Williams JI . McSwain NE Jr .
Institution: Dr. J. Ali, Department of Surgery, University of Toronto, 311-100 College Street, Toronto, Ont. M5G 1L5; Canada.
Title: Trauma patient outcome after the prehospital trauma life support program.
Source: Journal of Trauma-Injury Infection & Critical Care. Vol 42(6) (pp 1018-1022), 1997.
Abstract
Background: We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program.
Methods: Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS , n = 350).
Results: Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%). Length of stay and disability were statistically significantly decreased post-PHTLS . Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre- PHTLS mortality.
Conclusions: Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome. [References: 19]
*COPYRIGHT ELSEVIER SCIENCE B.V. 2002 - ALL RIGHTS RESERVED*
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Citation 4.
Authors: Ali J . Adam RU . Gana TJ . Bedaysie H . Williams JI .
Institution: Dr. J. Ali, Department of Surgery, University of Toronto, 311-100 College Street, Toronto, Ont. M5G 1LS; Canada.
Title: Effect of the prehospital trauma life support program (PHTLS) on prehospital trauma care.
Source: Journal of Trauma-Injury Infection & Critical Care. Vol 42(5) (pp 786-790), 1997.
Abstract:
Background: Improvement in trauma patient outcome has been demonstrated after the implementation of the Prehospital Trauma Life Support (PHTLS ) program in Trinidad and Tobago. This study was aimed at identifying prehospital care factors that may explain this improvement.
Methods: All patients transferred by ambulance to the major trauma referral hospital had assessment of airway control, oxygen use, cervical (C)-spine control, and hemorrhage control, as well as splinting of extremities during pre-PHTLS (July of 1990 to December of 1991; n = 332) and post-PHTLS periods (January of 1994 to June of 1995; n = 350). Pre-PHTLS data were compared with post- PHTLS data by chi2 analysis with a p value 0.05 being considered statistically significant.
Results: The frequency (%) increased in the post- PHTLS period for airway control (10 vs. 99.7%), C-spine control (2.1 vs. 89.4%), splinting of extremities (22 vs. 60.6%), hemorrhage control (16 vs. 96.9%), and oxygen use (6.6 vs. 89.5%) when no specific problem was identified. When a specific problem was identified in these areas, the post- PHTLS percentage also increased for airway control (16.2 vs. 100%), C-spine control (25 vs. 100%), splinting of extremities (33.9 vs. 100%), hemorrhage control (18 vs. 100%), and oxygen use (43.2 vs. 98.9%).
Conclusions: Prehospital trauma care has changed after the introduction of the PHTLS program as indicated by more frequent airway control, use of oxygen, control of cervical (C)-spine and hemorrhage, as well as splinting of fractures. This finding was evident not only as a routine but particularly when a specific related problem was identified. This change in prehospital care could be responsible for the improved trauma patient outcome after PHTLS. [References: 22]
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