Prehospital critical care is associated with increased survival in adult trauma patients in Scotland

Abstract

BackgroundScotland has three prehospital critical care teams (PHCCTs) providing enhanced care support to a usually paramedic-delivered ambulance service. The effect of the PHCCTs on patient survival following trauma in Scotland is not currently known nationally.MethodsNational registry-based retrospective cohort study using 2011–2016 data from the Scottish Trauma Audit Group. 30-day mortality was compared between groups after multivariate analysis to account for confounding variables.ResultsOur data set comprised 17 157 patients, with a mean age of 54.7 years and 8206 (57.5%) of male gender. 2877 patients in the registry were excluded due to incomplete data on their level of prehospital care, leaving an eligible group of 14 280. 13 504 injured adults who received care from ambulance clinicians (paramedics or technicians) were compared with 776 whose care included input from a PHCCT. The median Injury Severity Score (ISS) across all eligible patients was 9; 3076 patients (21.5%) met the ISS>15 criterion for major trauma. Patients in the PHCCT cohort were statistically significantly (all p<0.01) more likely to be male; be transported to a prospective Major Trauma Centre; have suffered major trauma; have suffered a severe head injury; be transported by air and be intubated prior to arrival in hospital. Following multivariate analysis, the OR for 30-day mortality for patients seen by a PHCCT was 0.56 (95% CI 0.36 to 0.86, p=0.01).ConclusionPrehospital care provided by a physician-led critical care team was associated with an increased chance of survival at 30 days when compared with care provided by ambulance clinicians.

Physician-augmented pre-hospital care in the Canadian context: the Jasper bus crash mass casualty incident

“…This allows for advanced resuscitation and earlier provision of hospital-based care, reducing the therapeutic vacuum that exists outside of the hospital setting. Literature focused on physician-augmented HEMS models suggest a possible mortality benefit in trauma patients when compared to ground EMS [3,4]. However, these data are derived from low quality studies with significant heterogeneity [3].…”

“…Physician-augmented HEMS systems allow for advanced trauma procedures beyond the critical care paramedic or nurse scope, including finger thoracostomy, resuscitative thoracotomy, lateral canthotomy, and limb amputation [4,6]. Beyond trauma care, pre-hospital physician delivery to resource-limited centres for inter-facility transport can allow for advanced medical interventions, such as difficult airway management, transvenous pacemaker insertion, linton tube placement, and central venous and arterial line insertion.…”

The Effect of Physician-Led Enhanced Care Teams in Prehospital Trauma Resuscitation

“…Motor vehicle accidents often result in severe trauma, which places the victim at high risk for death due to airway complications, chest injuries, and hemorrhagic shock [7]. Optimal management includes transporting the patient to the nearest trauma center as quickly and safely as possible for definitive trauma care.…”

“…While literature about ECTs in the U.S. is scarce, studies in European countries have found evidence in favor of physician-assisted response teams. Maddock et al discovered in Scotland that physician-led prehospital critical care teams (PHCCTs) resulted in reduced mortality in trauma patients, even when considering that patients who required PHCCTs generally had higher injury severity scores (ISS) [7]. Smith et al performed a study in the United Kingdom and were the first able to discern a risk-adjusted mortality benefit in patients treated by ECTs with no increase in morbidity [18].…”

Defining major trauma: a Delphi study

“…However, major trauma remains a relatively rare cause of death within England and Wales. In Scotland paramedic exposure to trauma accounts for 0.3% of case volume [ 3 ]. The lack of exposure to major trauma can cause anxiety and our perception of what is classified as major trauma is potentially complex.…”