Success Rate of Pre-hospital Emergency Medical Service Personnel in Implementing Pre Hospital Trauma Life Support Guidelines on Traffic Accident Victims.

OBJECTIVES: Road traffic injuries are responsible for a vast number of trauma-related deaths in middle- and low-income countries. Pre-hospital emergency medical service (PHEMS) provides care and transports the injured patients from the scene of accident to the destined hospital. The PHEMS providers and paramedics were recently trained in the Pre Hospital Trauma Life Support (PHTLS) guidelines to improve the outcome of trauma patients in developing countries. We decided to carry out a study on the success rate of PHEMS personnel in implementing PHTLS guidelines at the scene of trauma.
METHODS: Severe trauma patients who had been transferred to the emergency department were included in the study. Evaluations included transfer time, airway management, spinal immobilization, external bleeding management, intravenous (IV) line access, and fluid therapy. All evaluations were performed by an expert emergency physician in the emergency department.
RESULTS: The mean response time was 17.87±9.1 minutes. The PHEMS personnel immobilized cervical spine in 60.4% of patients, out of whom 16.7% were not properly immobilized. Out of 99 (98%) cases of established IV line access by the PHEMS providers, 57% were satisfactory. Fluid therapy, which was carried out in 99 (98%) patients by the PHEMS personnel, was appropriate in 92% of the cases.
CONCLUSIONS: PHEMS personnel need more education and supervising to provide services according to PHTLS guidelines.

Introduction

Road traffic injuries are responsible for a vast number of trauma-related deaths in middle- and low-income countries where 90% of total mortality occurs due to such injuries.1, 2 Pre-hospital emergency medical service (PHEMS) is a vital part of the health system and emergency safety net which provides care and transports injured patients from the scene of the accident to the appropriate hospital. In developing countries, the majority of road injury mortality takes place in the pre-hospital setting. Improvement in the PHEMS can thus reduce the related mortality and morbidity. At the scene of accident, PHEMS providers and paramedics should quickly recognize critically-injured patients, take the necessary measures, and transport the patients to an appropriate hospital.

Numerous studies have evaluated the time intervals in which PHEMS providers offer services to injured patients. The first 60 minutes after trauma has been referred to as the “golden hour” by trauma experts. Previous studies suggested that increased pre-hospital time intervals are associated with increased mortality and morbidity rates in severe trauma patients.7, 8

PHEMS providers and paramedics in low- and middle-income countries have recently been trained in the Pre Hospital Trauma Life Support (PHTLS) guidelines to improve the outcome of trauma patients. However, there is little information on the success rate of PHEMS providers in achieving the international standards. A German study has lately suggested that PHEMS providers make many mistakes and unsafe actions in PHEMS scenarios.

Considering the abovementioned facts, we decided to carry out a study on the success rate of PHEMS personnel in implementing PHTLS guidelines at the scene of trauma.

Materials and Methods

In a prospective cross-sectional study completed during March-September 2011, 101 severe trauma patients who had been transferred to the emergency department (ED) of Imam Reza Hospital (Tabriz, Iran) by PHEMS agencies, all nurses or paramedics, were included. Severe trauma was defined as an injury severity score (ISS) of over 15.11, 12 The study was undertaken in Tabriz, the capital city of East Azerbaijan Province, Iran with a population of 1,400,000.

Trauma management and care during transportation of the patients by PHEMS providers were evaluated against the 6th edition PHTLS. Evaluations included response time, airway management, spinal immobilization, external bleeding management, intravenous (IV) line access, and fluid therapy. All evaluations were carried out by an expert emergency physician in the ED. The data related to response time, defined as the time from alarm activation at the agency to arrival of the first responding ambulance at the scene, was obtained from the ambulance dispatch center. The data was assessed and mean response time was calculated. Airway management was defined as the implementation of maneuver, airway device, and intubation.

Due to the double-blind design of the study, the PHEMS providers were not aware of the study protocol. Likewise, the emergency physician who evaluated the PHEMS providers was not informed about their names and identification.

Ethical Consideration

Ethical approval was obtained from the Medical Ethics Committee of Tabriz University of Medical Sciences. Furthermore, due to the lack of any interventions on the patients, no written informed consents were obtained from the studied population. This research was accepted by the Deputy of Research of the Faculty of Medicine, Tabriz University of Medical Science.

Data Analysis

Data was presented as mean±standard deviation (SD) or percentage. Statistical analyses were performed in SPSS16 for Windows (SPSS Inc., Chicago, IL, USA) using chi-square, Fisher's exact, and independent samples-t tests wherever appropriate. P values less than 0.05 were considered statistically significant.

Results

Overall, 100 subjects with a mean age of 33.19±21.18 years were studied. While 43.9% of the injuries occurred in urban areas, 56.1% took place in interurban roads and semi-urban regions. The most frequent cause of trauma was motor vehicle collision (Table 1). There was a significant association between the location and type of trauma. While motor vehicle collisions were more frequent in urban areas, motor vehicle roll-overs were more common in interurban roads (p≤0.001).

Table 1

The frequencies of trauma causes

Trauma cause	Frequency
Car-car accident	57
Pedestrian accident	21
Motorcycle–car accident	12
Motorcycle roll over	11

The mean response time for the arrival of PHEMS at the scene of accident was 17.87±9.1 (95% confidence intervals) minutes (range: 1–60 minutes) (Figure 1). The mean response time was 13.35±8.9 minutes for urban accidents and 21.51±7.77 (95% confidence intervals) minutes for interurban and semi-urban regions. The response time for interurban road injuries was significantly longer than urban areas (p≤0.001).

Figure 1

The mean response time for the arrival of PHEMS.

Indication of airway management was evaluated by an expert emergency physician according to the PHTLS guidelines. Among patients being transported to the ED, 21% had indications of airway maneuver, 19% had indications of airway device placement, and 12.1% had indications of intubation. However, the three airway management methods had been carried out by the PHEMS personnel only in 20.8% of all cases.

The PHEMS personnel immobilized cervical spine in 60.4% of patients, out of whom 16.7% were not correctly immobilized. There were no significant associations between the location of trauma and quality of neck immobilization (p=0.39). Moreover, in 31.7% of patients thoracolumbar spine was immobilized using a long back board.

All patients had external bleeding (i.e. every kind of bleeding in the head, trunk, and limbs), of which 60% were correctly managed by the PHEMS personnel. There was no significant relationship between the location of trauma and the quality of bleeding management (p=0.228).

The PHEMS providers established 99 cases (98%) of IV line access out of which 57% were satisfactory. The rest of the IV lines were not inserted correctly or in the proper limb. The quality of IV line access was not significantly different between urban and interurban road injuries (p=0.627).

Fluid therapy, which was carried out in 99 (98%) patients by the PHEMS personnel, was appropriate in 92% of the cases. In 8% of the cases, the fluid was chosen incorrectly and administered more or less than expected. There was no significant difference in the quality of fluid therapy between urban and interurban road injuries (p=0.275).

Discussion

PHTLS guidelines have been commonly used in training PHEMS providers in low- and middle-income countries. In the present study, we tried to evaluate the efforts of PHEMS providers in trauma patient care based on PHTLS guidelines. To the best of our knowledge, no similar studies have been carried out in developing countries such as Iran.

In a study carried out in northwest Iran, most cases of severe trauma (Injury Severity Score >15) were in interurban roads; however, in our study most severe trauma injuries occurred in urban areas.

Our “dispatch-beginning-to-scene-arrival interval” was longer than previous studies. In an American study, the response time was 4.28 minutes. An Iranian study reported a response time of 10.6 minutes, while another study in Tehran (the capital city of Iran) found the mean response time to be 10 minutes. Furthermore, in our study, the mean measured time on interurban road injuries was significantly longer than urban areas. Taking this into consideration, the response time of PHEMS is not acceptable.

The most frequent accidents in urban areas were motor vehicle roll-overs. Speed control can therefore decrease the number of trauma events.

According to the PHTLS guidelines, in a severe trauma case for which the time to the hospital is more than 30 minutes, patients should be intubated at the scene. In the presented study, according to PHTLS, although 52% of patients had indications of airway management (maneuver, airway device management, and intubation), only 20.8% were appropriately managed by PHEMS providers. This finding indicates that the PHEMS providers failed in airway management of severe trauma patients.

PHTLS guidelines suggest that spinal immobilization should be performed in all severe trauma patients. In our study, however, immobilization was only partially applied.

According to PHTLS, IV lines should be established for all severe trauma patients in interurban areas. In our study, nearly all patients, even those who had been injured in urban regions, had IV line access. While Gonzalez et al. reported a 79% success rate in IV line access, the success rate of IV line was not satisfactory (57%) in this study. However, any delay in IV line access may increase the “on-scene” time.

Some studies suggested the fluid therapy en route for trauma patients is ineffective. In contrast, based on PHTLS guidelines, fluid therapy is essential for severe trauma patients in interurban road injuries.17, 18 The PHEMS providers performed fluid therapy for almost all patients. Nearly all fluids were selected properly and the amounts of fluids were administered exactly.

Limitation

Research would be more effective if completed over the course of an entire year so topographic and climate interference can be taken into consideration.

This research was done only for EMS of one provience. It may be more effective to complete this study in multiple provinces and then compare results.

Conclusion

The PHEMS providers failed to perform PHTLS guidelines at the scene of accident.

Conflict of Interest

The authors declare that there is no potential conflicts of interest.