An evaluation of paramedic activities in prehospital trauma care

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Injury Vol. 28, No. 9-10, pp. 623-627, 1997 © 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383/97 $17.00 + 0.00

PIh S0020-1383(97)00125-3

An evaluation of paramedic activities in prehospital trauma care T. H. Rainer', K. P. G. H o u l i h a n 1, C. E. R o b e r t s o n ~, D. Beard 2, J. M. H e n r y 2 a n d M. W. G. G o r d o n 3 1Department of Accident and Emergency Medicine, 2Scottish Trauma Audit Group, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK and 3Department of Accident and Emergency Medicine, Southern General Hospital, Glasgow, Scotland, UK

The object of the study was to identify the effect paramedics have on prehospital trauma care and evaluate their influence on outcome compared to that of ambuhmce technicians. A prospective review of ambulance and hospital records was conducted over 2 years from 1 August 1993 to 31 July 1995. The setting for the study was the Royal Infirmary of Edinburgh and its primary response catchment area served by the South-East Region of the Scottish Ambulance Service central control room. The study involved 1090 patients brought to hospital by ambulance who met the entry criteria for the Scottish Trauma Audit Group study. The results show that paramedics spend significantly longer at scene than the ambulance technicians; however, there was no difference in total prehospitaI times between the groups. Paramedics direct a significantly higher proportion of patients to the resuscitation room and significantly more of these patients go to theatre, intensive care or the mortuary. There is no reduction in mortality or length of stay in intensive care in the paramedic group. The authors conclude that paramedics deliver an improved process of care but their activities do not significantly reduce mortality or length of stay in intensive care. © 1997 Elsevier Science Ltd. All rights reserved.

Injury, Vol. 28, No. 9-10, 623-627, 1997

Introduction The recognition of the major contribution made by trauma to death and loss of productive life in the United Kingdom (UK) has stimulated considerable interest over the past decade. In particular, attention has focused on trauma systems and the relative contributions made by their separate components. Attempts to extrapolate from the experience of other countries to our situation emphasizes the diverse and separate nature of needs and outcomes. The patterns of trauma aetiology in North America vary markedly from that in the UK 1 3. In the United States, gunshot injury is the second most common cause of death from trauma, while in the UK,

penetrating injury forms only a small component of our workload ~6. Geographical and meteorological differences, the demographic profiles of the patients and the levels and quality of prehospital and in-hospital facilities are also notably different. Irrespective of these differences, most of the recent developments in the UK have been stimulated by observation of North American practice. While understandable, this policy is fraught with actual and potential pitfalls. Some of these features are reflected in the trimodal distribution of trauma deaths 7. Reported from North America, this gave rise to the emotive term 'the Golden Hour' and became a cornerstone for the rationale of introducing advanced life support techniques in prehospital care "-~2. In the UK, however, there is no evidence that the deaths of adults after trauma follow a trimodal distribution 13. Even in North America where initiatives were introduced in the 1970s and 1980s to address prehospital care delivery 14-16, there is an absence of prospective, randomized, controlled trials to assess their efficacy. Nevertheless, it was decided by the Department of Health that, by 1995, every front-line ambulance should carry at least one fully trained and equipped paramedic crew member~7,~L Attempts have been made in the UK to quantify some elements of the problem. The contribution made by an integrated trauma system has been independently evaluated and compared to existing arrangements by carefully performed prospective studies using objective assessments of efficacylL For the component of prehospital care, however, the situation is less clear. One report suggested that death was potentially preventable in at least 39 per cent of those who died from accidental injury before reaching hospital 2°. By contrast, a study of over 25000 patients transported to hospital by 999 ambulance indicated that there was only one patient in whom the use of advanced trauma techniques by

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Injury: International Journal of the Care of the Injured Vol. 28, No. 9-10, 1997

ambulance crews could have improved the probability of long-term survivaF'. This prospective study evaluates the relative contributions made by ambulance paramedics using advanced life-support techniques and basic trained ambulance technicians to the clinical management and mortality of trauma patients.

Patients and methods A prospective study was performed on trauma patients admitted via ambulance to the Accident and Emergency Department of the Royal Infirmary of Edinburgh over a 2-year period from 1 August 1993 to 31 July 1995. Patients who fulfilled the entry criteria of the Scottish Trauma Audit Group (STAG) were included in the analysis. The entry criteria are those of the Major Trauma Outcome Study4; trauma patients who are admitted to hospital for a period of 3 days or more, are managed in an intensive therapy or high dependency unit, are transferred to or from the participating hospital, or who die in hospital. Patients aged over 65 with an isolated fracture of the neck of the femur or pubic ramus and children aged under 13 are exluded. Data were collected with regard to mechanism and type of injury, prehospital times (response, on-scene and transport) and triage category on arrival in the Accident and Emergency Department. Physiological observations of heart rate, blood pressure, respiratory rate and Glasgow Coma Scale were noted. One-scene interventions including tracheal intubation and intravenous cannulation and fluid administration were obtained from the Scottish Ambulance Service patient report form. Injury Severity scores (ISS), Revised Trauma Scores (RTS) and probabilities of survival (Ps) were calculated for each patient =-=4. Patients were excluded from the analysis if ambulance personnel interventions at scene could not be ascertained or factors outside the control of the ambulance service had influenced prehospital care, for example, entrapment or the attendance of the hospital-based medical team. The level of ambulance response to an individual incident is determined by central ambulance control and is dependent on the first available ambulance closest to the incident. Paramedics and ambulance technicians assess, triage and treat trauma victims according to accepted NHSTD guidelines '7. Paramedics, however, have received specialized training in orotracheal intubation, peripheral percutaneous intravenous cannulation and the administration of fluids. Data were entered and analysed using SPSS for WindowsC Chi-squared and Mann-Whitney U analyses were performed with the significance level set at p