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The journal of trauma and acute care surgeryJournal Article

01 Mar 2025

Emergency medical services level of training is associated with mortality in trauma patients: A combined prehospital and in hospital database analysis.

Background

There is conflicting evidence regarding emergency medical service (EMS) provider level of training and outcomes in trauma. We hypothesized that advanced life support (ALS) provider transport is associated with lower mortality compared with basic life support transport.

Methods

We performed secondary analysis of a combined prehospital and in-hospital database of trauma patients utilizing ESO electronic medical records from 2018 to 2022. We included encounters with patients aged 15 years to 100 years transported by ground to a Level I or II trauma center with trauma-specific ICD-10-CM codes. Patients dead upon EMS arrival and transfers were excluded. We matched patients using 1:1 nearest neighbor propensity scores based on demographic, injury, and EMS characteristics, prehospital vitals, and trauma center designation. The exposure variable was EMS level of training and outcome was mortality. We conducted subgroup analyses on predefined cohorts (age > 50 years, mechanism of injury, prehospital EMS time > 30 minutes).

Results

We identified 30,735 ALS and 1,758 basic life support encounters, representing 1,154 pairs following propensity matching. Mortality was lower among patients transported by ALS providers (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.18-0.88; p = 0.023). Mortality was also lower in the subgroups of patients aged > 50 years (OR, 0.35; 95% CI, 0.13-0.98; p = 0.046), and in patients with mechanisms of injury excluding falls (OR, 0.35; 95% CI, 0.13-0.98; p = 0.047). In those with prolonged prehospital time, the association approached significance (OR, 0.30; 95% CI, 0.08-1.08; p = 0.067). In those with mechanisms of injury of fall, the association was not significant.

Conclusion

In this retrospective, propensity matched cohort study using a national sample of trauma patients, attendance by ALS providers was associated with reduced mortality. This was observed in the entire cohort, in those aged > 50 years, and those with a higher-risk mechanism of injury. It approached significance in those with prolonged prehospital time.

Level of evidence

Therapeutic/Care Management; Level III.

References:

  • Centers for Disease Control and Prevention. Top Ten Leading Causes of Death in the US for Ages 1–44 form 1981 to 2022 . Web-Based Injury Statistics Query and Reporting System Web site. Available at: https://www.cdc.gov/injury/wisqars/animated-leading-causes.html. Accessed October 01, 2024.
  • Carroll SL Dye DW Smedley WA Stephens SW Reiff DA Kerby JD, et al. . Early and prehospital trauma deaths: who might benefit from advanced resuscitative care? J Trauma Acute Care Surg. 2020;88(6):776–782.
  • Davis JS Satahoo SS Butler FK Dermer H Naranjo D Julien K, et al. . An analysis of prehospital deaths: who can we save? J Trauma Acute Care Surg. 2014;77(2):213–218.
  • Gewiess J Albers CE Pape HC Bangerter H Zech WD Keel MJB, et al. . Characteristics of prehospital death in trauma victims. J Clin Med. 2021;10(20):4765.
  • Tomas C, Kallies K, Cronn S, Kostelac C, deRoon-Cassini T, Cassidy L. Mechanisms of traumatic injury by demographic characteristics: an 8-year review of temporal trends from the National Trauma Data Bank. Inj Prev. 2023;29(4):347–354.

Article info

Journal issue:

  • Volume: 98
  • Issue: 3

Doi:

10.1097/TA.0000000000004540

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