A Traumatic Tale of 2 Cities: Does EMS level of care and transportation model affect survival in trauma patients transported to Level 1 trauma centres? Colin Rouse1 Jefferson Hayre1 Dr. James French2 Ian Watson3 Sue Benjamin3 Jacqueline Fraser4 Beth Sealy5 Dr. Mete Erdogan5 Dr. Robert Green5,6 Dr. Paul Atkinson 1,2,3 Dalhousie Medicine New Brunswick, Saint John, New Brunswick1 Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick2 New Brunswick Trauma Program, Saint John, New Brunswick3 Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick4 Nova Scotia Trauma Program, Halifax, Nova Scotia5 Department of Emergency Medicine, Dalhousie University, QEII Health Sciences Centre, Halifax, Nova Scotia6
Standard Emergency Medical System (SEMS) VS Advanced Emergency Medical System (AEMS)
Research Question Null Hypothesis Apparent differences in prehospital care between a standard emergency medical system and an advanced emergency medical system do not affect survival to hospital in all trauma patients with an ISS 13 or in those patients with severe injuries (ISS>24). Primary Outcome Survival to Hospital Secondary Outcomes Survival to 30 days or discharge from hospital
Methodology Inclusion April 1, 2011 March 31, 2013 Adult Trauma Patients (age>15) Injury Severity Score (ISS) >12 Direct Transfers by EMS Exclusion Transfer Patients Drowning, Asphyxiation, Burns Children Prehospital deaths with no interventions by EMS
Case Inclusion Standard Emergency Medical System Advanced Emergency Medical System
Descriptive Findings 0.60 ISS Distribution 0.50 0.50 0.46 0.40 Proportion 0.30 0.20 0.18 0.22 0.32 0.28 0.10 0.00 Severity I (ISS 13 15) Severity II (ISS 16 24) Severity III (ISS 25 40) Standard Emergency Medical System Advanced Emergency Medical System
Results Proportion 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0.95 0.92 Survival Rate 0.55 0.55 Overall ISS >24 Survival Proportion in a Standard Emergency Medical System Survival Proportion in an Advanced Emergency Medical System SEMS AEMS Significance Overall Survival 0.95 (n=96) 0.92 (n=232) p = 0.49 Survival ISS >24 0.55 (n=18) 0.55 (n=44) p = 1.00
Results Proportion 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Survival to 30 days or discharge 0.84 SEMS 0.78 AEMS SEMS AEMS Significance Overall Survival 0.84 (n=96) 0.78 (n=232) p = 0.19
Limitations Small Sample Size Selection Bias Single source of data No Adjustment for Confounding Variables Results are aggregate No case level data
Conclusion Overall Survival to hospital was the same between advanced and standard Canadian EMS systems. Individual case benefit cannot be excluded as the sample size was low. Case level data sharing is needed to permit analysis of potential confounding variables
References 1.Cardinal M, Crain J, Do MT, Fréchette M, McFaull S, Skinner R, Thompson W. Report summary injury in review, 2012 edition: spotlight on road and transport safety. Chronic Dis Inj Can 2012 Sept; 32(4): 229 30. 2.Halcomb E, Daly J, Davidson P, Elliot D, Griffiths R. Life beyond severe traumatic injury: an integrative review of the literature. Aust Crit Care 2005 Feb; 18(1):17 18, 20 24. 3.Celso B, Tepas J, Langland Orban B, Pracht E, Papa L, Lottenberg L, Flint L. A systematic review and meta analysis comparing outcome of severly injured patients treated in trauma centres following the establishment of trauma systems. J Trauma 2006; 60(2): 371 8. 4.Statistics Canada. Census of Population, 2011: Census Tract (CT) Profiles, [Table]. Statistics Canada 2011. Retrieved from: http://www12.statcan.gc.ca/census recensement/2011/ 5.Ryynanen O, Iirola T, Reitala J, Palve H, Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med. 2010; 18(11): 62. 6.Isenberg DL, Bissell R. Does advanced life support provide benefits to patients?: A literature review. Prehosp Disaster Med. 2005;20(04):265 270.
References 7.von Vopelius Feldt J, Wood J, Benger J. Critical care paramedics: Where is the evidence? a systematic review. Emerg Med J. 2013. doi: 10.1136/emermed 2013 202721; 10.1136/emermed 2013 202721. 8.Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS major trauma study: Impact of advanced life support on survival and morbidity. CMAJ. 2008;178(9):1141 1152. doi: 10.1503/cmaj.071154; 10.1503/cmaj.071154. 9.Bakalos G, Mamali M, Komninos C, et al. Advanced life support versus basic life support in the pre hospital setting: A meta analysis. Resuscitation. 2011;82(9):1130 1137. 10.Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, Harvey E, Wright A, Henderson K, Baker D, Ranson S, ReMine S. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010 Nov Dec; 67(6): 439 443. 11.Cole EM, West A, Davenport R, Naganthar S, Kanzara T, Carey M, Brohi K. Can residents be effective trauma team leaders in a major trauma centre? Injury 2013 Jan; 44(1): 18 22. 12.Huber Wagner S, Lefering R, Qvick L M, Körner M, Kay MV, Pfeifer K J, Reiser M, Mutschler W, Kanz K G. Effect of whole body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009 Apr 373: 1455 1461.
Data Sharing 1.Analysis of Nova Scotia Trauma Program Register on site at EHS Nova Scotia by approved data analyst compliant with NSTP data processing policy. 2.Analysis of New Brunswick Trauma Program Register on site at Saint John Regional Hospital by approved data analyst compliant with NSTP data processing policy. 3.Operational and Performance Analysis results transferred securely (on Truecrypt AES 256 bit encrypted media) to New Brunswick Trauma Program by identified approved data analyst. Only pooled results are transferred. No individual patient fields are transferred. 4.Pooled results housed in New Brunswick Trauma Program (an approved and regulated data custodian of trauma data) 5.Pooled results data compared using statistical hypothesis testing (then disseminated).