International comparison of prehospital trauma care systems

Roudsari, Bahman S.; Nathens, Avery B.; Cameron, Peter; Civil, Ian; Gruen, Russel L.; Koepsell, Thomas D.; Lecky, Fiona E.; Lefering, Rolf L.; Liberman, Moishe; Mock, Charles N.; Oestern, Hans-Jörg; Schildhauer, Thomas A.; Waydhas, Christian; Rivara, Frederick P.

doi:10.1016/j.injury.2007.03.028

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Volume 38, Issue 9 , Pages 993-1000, September 2007

International comparison of prehospital trauma care systems

Bahman S. Roudsari
- Department of Epidemiology, University of Texas, School of Public Health, Dallas, USA
- Corresponding author. Tel.: +1 214 648 1054; fax: +1 214 648 1081.
Avery B. Nathens
- St. Michael's Hospital, Toronto, Canada
Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash School of Public Health, Alfred Hospital, Australia
Ian Civil
- University of Auckland, Auckland Hospital, Auckland, New Zealand
Russel L. Gruen
- Department of Health Services Research and Policy, Menzies School of Health Research, Australia
Thomas D. Koepsell
- Harborview Injury Prevention and Research Centre, Department of Epidemiology, University of Washington, Seattle, USA
- Harborview Injury Prevention and Research Centre, Department of Health Services, University of Washington, Seattle, USA
Fiona E. Lecky
- University of Manchester, Department of Emergency Medicine, Manchester, United Kingdom
Rolf L. Lefering
- Biochemical & Experimental Division, University of Cologne, Cologne, Germany
Moishe Liberman
- Montreal General Hospital, McGill University Health Centre, Divisions of Surgery and Clinical Epidemiology, Montreal, Canada
Charles N. Mock
- Harborview Injury Prevention and Research Centre, Department of Surgery, University of Washington, Seattle, USA
- Harborview Injury Prevention and Research Centre, Department of Epidemiology, University of Washington, Seattle, USA
Hans-Jörg Oestern
- Chefarzt der Klinik für, Unfall und Wiederherstellungschirurgie, Allgemeines Krankenhaus Celle, Germany
Thomas A. Schildhauer
- Chirurgische Klinik und Poliklinik, BG Kliniken Bergmannsheil, Ruhr-Universitat Bochum, Bochum, Germany
Christian Waydhas
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Essen, Hufelandstr., Germany
Frederick P. Rivara
- Harborview Injury Prevention and Research Centre, Department of Pediatrics, University of Washington, Seattle, USA
- Harborview Injury Prevention and Research Centre, Department of Epidemiology, University of Washington, Seattle, USA

Accepted 27 March 2007.

Summary

Objective

Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients’ outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems.

Methods

Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP) <90mmHg) and early trauma fatality rate (i.e. death during the first 24h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes.

Results

After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73–1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54–0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems.

Conclusion

These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.

Keywords: Emergency medical services (EMS), Trauma, Injury, International, Mortality, Clustered study, Shock rate, Intracluster correlation coefficient (ICC)