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Contents lists available at SciVerse ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

1 Clinical paper

2 Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and

3 impact on survival of trauma victims夽
4 Q1 Jakob Johansson a,b,∗ , Hans Blomberg a,b , Bodil Svennblad c , Lisa Wernroth c , Håkan Melhus e ,
5 Liisa Byberg a,c , Karl Michaelsson c,d , Rolf Karlsten a , Rolf Gedeborg a,c
a
6 Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
b
7 Centre of Emergency Medicine, Uppsala University Hospital, Uppsala, Sweden
c
8 Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
d
9 Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden
e
10 Department of Medical Sciences, Uppsala University, Uppsala, Sweden
11

12 a r t i c l e i n f o a b s t r a c t
13
14 Article history: Background: The Prehospital Trauma Life Support (PHTLS) course has been widely implemented and
15 Received 21 November 2011 approximately half a million prehospital caregivers in over 50 countries have taken this course. Still, the
16 Received in revised form 23 January 2012 effect on injury outcome remains to be established. The objective of this study was to investigate the
17 Accepted 10 February 2012
association between PHTLS training of ambulance crew members and the mortality in trauma patients.
Available online xxx
Methods: A population-based observational study of 2830 injured patients, who either died or were hospi-
18
talized for more than 24 h, was performed during gradual implementation of PHTLS in Uppsala County in
19 Keywords:
Sweden between 1998 and 2004. Prehospital patient records were linked to hospital-discharge records,
20 Trauma
21 Advanced life support cause-of-death records, and information on PHTLS training and the educational level of ambulance crews.
22 Prehospital Trauma Life Support The main outcome measure was death, on scene or in hospital.
23 Survival Results: Adjusting for multiple potential confounders, PHTLS training appeared to be associated with a
reduction in mortality, but the precision of this estimate was poor (odds ratio, 0.71; 95% confidence
interval, 0.42–1.19). The mortality risk was 4.7% (36/763) without PHTLS training and 4.5% (94/2067)
with PHTLS training. The predicted absolute risk reduction is estimated to correspond to 0.5 lives saved
annually per 100,000 population with PHTLS fully implemented.
Conclusions: PHTLS training of ambulance crew members may be associated with reduced mortality in
trauma patients, but the precision in this estimate was low due to the overall low mortality. While
there may be a relative risk reduction, the predicted absolute risk reduction in this population was
low.
© 2012 Published by Elsevier Ireland Ltd.

24 1. Introduction This strategy has high face validity, but the underlying evidence is 32

poor.3 33

25 Trauma is the leading cause of death among persons below 60 In the late 1970s, the American College of Surgeons Com- 34

26 years of age.1 It is a well-established belief that optimal treatment mittee on Trauma developed the Advanced Trauma Life Support 35

27 in the early phase after trauma has a major impact on mortality.2 (ATLS) course for physicians.4,5 Although implemented world- 36

28 Therefore, over the years, raising the educational level among pre- wide, there is still no strong evidence that ATLS lowers mortality 37

29 hospital caregivers and the implementation of specific educational in trauma victims.6,7 According to a recent study, ATLS-training 38

30 programs that target trauma care have been two widely adopted might even impair outcome.8 The Prehospital Trauma Life Support 39

31 strategies aimed at improving the outcome for trauma victims. (PHTLS) program was introduced in 1983 to integrate prehospital 40

trauma care with the ATLS program.9 PHTLS has been recog- 41

nized as one of the leading educational programs for prehospital 42

emergency trauma care and approximately half a million pre- 43

夽 A Spanish translated version of the summary of this article appears as Appendix hospital caregivers in over 50 countries have taken this course.9 44
in the final online version at doi:10.1016/j.resuscitation.2012.02.018. However, the scientific support for improved patient outcome 45
∗ Corresponding author at: Department of Surgical Sciences – Anaesthesiology &
is limited, and there is no evidence to recommend advanced 46
Intensive Care, Uppsala University Hospital, S-751 85 Uppsala, Sweden.
Tel.: +46 18 6110000; fax: +46 18 559357. life-support (ALS) training for ambulance crews.10–12 Substantial 47

E-mail address: jakob.johansson@surgsci.uu.se (J. Johansson). effort and money are put into the PHTLS training program and 48

0300-9572/$ – see front matter © 2012 Published by Elsevier Ireland Ltd.

doi:10.1016/j.resuscitation.2012.02.018

Please cite this article in press as: Johansson J, et al. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on
survival of trauma victims. Resuscitation (2012), doi:10.1016/j.resuscitation.2012.02.018
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49 there is an obvious need to evaluate the possible benefits for There were no major changes in the standard of pre-hospital 105

50 patients. trauma care or equipment used during the study period. All 106

51 The aim of this study was to investigate the association between ambulance crew members in the organisation were trained and 107

52 PHTLS training of ambulance crew members and the outcome in authorized to perform trauma care according to international stan- 108

53 trauma patients. dard treatment, except from endotracheal intubation. A PHTLS 109

certification did not change the authorization to use any equipment 110

54 2. Methods or perform any specific intervention. 111

55 2.1. Source population 2.5. Outcome 112

56 Uppsala County is an administrative region for health care in Prehospital injury deaths were defined as autopsied injury 113

57 Sweden, with a population of 302,564 and a population density of deaths not associated with a hospital admission.19 Only prehos- 114

58 43 inhabitants/km2 in 2004. There are two hospitals in the county; pital deaths with documented involvement of ambulance services 115

59 Uppsala University Hospital, a 1100-bed tertiary care facility, and were included. Hospital death was defined as death during a hos- 116

60 Enköping Hospital, a small local hospital handling only minor pital stay with a principal discharge diagnosis indicating injury. 117

61 trauma. The composite outcome of either prehospital or hospital death was 118

studied. 119

62 2.2. Emergency Medical Service (EMS)-system

2.6. Possible confounders 120

63 The ambulance staff consisted of registered nurses and emer-

The International Classification of disease Injury Severity Score 121
64 gency medical technician (EMT) equivalents (nursing assistants
(ICISS) was calculated based on diagnosis-specific survival prob- 122
65 with special ambulance training). During the study period the num-
abilities for individual injury ICD-10 codes.20–22 For descriptive 123
66 ber of registered nurses employed as ambulance crew members
purposes, ICISS was categorized as critical (0–0.219), severe 124
67 increased rapidly. Prior to and during the study period all ambu-
(0.220–0.354), serious (0.355–0.664), moderate (0.665–0.940), or 125
68 lance crew members were, as part of their regular skill practice,
minor (0.941–1.0). Injury severity estimates based on the Revised 126
69 annually trained and authorized to provide ALS in medical emer-
Trauma Score (RTS) were also available.23 127
70 gencies and trauma, with the exception of endotracheal intubation
Each victim’s injuries were categorized according to the injury 128
71 (only performed in cardiac arrest) and chest drainage.
mortality diagnosis matrix for ICD-10.24 Five categories of major 129

injury regions (head, spinal cord, thorax, abdomen, and pelvis) were 130
72 2.3. Study population defined from the matrix. 131

Causes of injury were classified according to the matrix devel- 132

73 All primary incident hospital admissions for injury in the county oped by the National Center for Health Statistics, Centers for Disease 133
74 of Uppsala from 1998 through 2004 were extracted from the Control, USA.25 Data was collapsed to three categories: traffic 134
75 Swedish National Patient Registry (NPR).13 Injury deaths, where injuries, falls, and other injuries. 135
76 the underlying cause of death was V01-Y36 according to ICD-10,14 The basic educational level (nurse or EMT equivalent) and 136
77 were extracted from the Cause of Death Registry (CDR). These employment time of the ambulance crew members were also con- 137
78 codes include all external causes of injury except those referring sidered as potential confounders. Exposure status was determined 138
79 to “Complications of medical and surgical care”, “Sequelae of exter- from the highest educational level and the longest work experience 139
80 nal causes of morbidity and mortality”, and “Supplementary factors in the ambulance crew. To account for a possible period effect (such 140
81 related to causes of morbidity and mortality classified elsewhere”. as changes in trauma care over time during the study period), the 141
82 These datasets were combined using the unique personal identifi- calendar year of the injury was included in the multivariable mod- 142
83 cation number for person-based linkage.15 Admissions resulting in els. The patients’ age and sex were also considered as potential 143
84 a hospital stay of one day or less and discharge alive were excluded confounders. 144
85 to reduce the number of minor injuries included.16 Dispatch infor-
86 mation, prehospital time intervals, medical information, and the 2.7. Statistics 145
87 identity of the ambulance crew members were added from prehos-
88 pital electronic patient records.17 For each individual ambulance Multivariable logistic regression analysis was used to model the 146
89 crew member the following information was collected: years of composite outcome of prehospital or hospital death using all the 147
90 employment in health care services and in ambulance services; the possible confounders described above. Collinearity was assessed 148
91 date for exam as a registered nurse and the date for PHTLS train- from variance inflation factors. Both age and calendar year of injury 149
92 ing. The final dataset consisted of 2830 injury events with complete were entered as linear effects in the models based on inspec- 150
93 data (Fig. 1). The study was approved by the regional Human Ethics tion of a logit plot of each variable. ICISS was used after logit 151
94 Committee. transformation.26 Effect-measure modification was evaluated by 152

including product terms between the exposure variable and injury 153

95 2.4. Exposure severity (ICISS) and year, respectively. The multivariable logistic 154

regression model was also used to calculate the predicted mortal- 155

96 The PHTLS program is a standardized curriculum for prehos- ity for each injury event. The difference in mean predicted mortality 156

97 pital caregivers. The core component is a 16-h course with a between the PHTLS group and the non-PHTLS group estimated the 157

98 mixture of lectures and interactive skill stations.18 If at least one absolute risk reduction. 158

99 ambulance crew member was PHTLS certified (had passed the Population-averaged models using generalized estimation 159

100 final examination in PHTLS), the injured patient was considered equations (GEE) were used to handle correlations from ambulance 160

101 exposed. Exposure status was not dependent on whether the certi- crews appearing multiple times in the dataset and patients appear- 161

102 fied crewmember was in charge of the crew or not. The time elapsed ing multiple times in the study population.27,28 The number of 162

103 since PHTLS certification was considered in a sensitivity analysis. lives potentially saved annually was estimated by the proportion 163

104 No refresher courses were performed during the study period. of eligible patients corresponding to the estimated absolute risk 164

Please cite this article in press as: Johansson J, et al. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on
survival of trauma victims. Resuscitation (2012), doi:10.1016/j.resuscitation.2012.02.018
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5235 severe injuries (hospitalized > 1 day or dead) with documented participation of EMS

483 without a valid personal

identification number in EMS record

Information on educational level 1129 with incomplete information to

among ambulance personnel added determine crew PHTLS certification
status

3623 severe injuries (hospitalized > 1 day or dead) with documented participation of EMS and
information on ambulance crew’s PHTLS certification status

793 without complete information on

both crew members’ identity and
PHTLS certification status and
covariates

2830 incident injuries (hospitalized > 1 day or dead) with documented participation of EMS and
information on identity and PHTLS certification status for both members of the ambulance
crew and all covariates in the multivariable model

Fig. 1. Flow diagram for selection of the study population. EMS: Emergency Medical Service.

165 reduction. All analyses were done as complete subjects analyses. 0.41–1.25), with a corresponding predicted absolute risk reduc- 192

166 As a sensitivity analysis, multiple imputation using predictive mean tion of 0.2%. There was no indication of serious collinearity in the 193

167 matching (aregImpute) that fits separate flexible additive imputa- regression model, with the highest variance inflation factor being 194

168 tion models, was also applied.29,30 Missing data for PHTLS status 1.78. 195

169 and employment time were imputed based on mortality, PHTLS sta- This analysis, however, violates the assumption of independent 196

170 tus, educational level (nurse/EMT), calendar year, and employment observations since the same ambulance crews were involved in 197

171 time. Ten bootstrap samples were generated. many cases of injury and also the same patients occurred multi- 198

172 The statistical packages SAS version 9 (SAS Institute Inc., Cary, ple times in the study population. We analytically considered such 199

173 NC, USA) and R version 2.9.2 (R Foundation for Statistical Comput- possible correlations (supplementary data: table* 4). Results from 200

174 ing, Vienna, Austria) were used for data management and statistical these analyses were very similar to those from using standard logis- 201

175 analyses. tic regression. The choice of variance structure did not affect the 202

result and, in general, the correlations were minimal (<0.1). 203

176 3. Results
3.3. Subgroup analyses 204

177 3.1. Cohort characteristics

A product term for PHTLS and injury severity in the logistic 205

178 During the 7-year study period, EMSs responded to 2830 injury regression model indicated the possible presence of effect-measure 206

179 events with complete data for the analyses (Fig. 1). The proportion modification (likelihood ratio test P = 0.08), but analysis stratified 207

180 of injury events handled by ambulance crew members with PHTLS for injury severity did not indicate any substantial influence on 208

181 training increased over time (Fig. 2). There were no major differ- the estimated OR for PHTLS (Table 2). Exclusion of injuries caused 209

182 ences in patient characteristics; however, ambulance crews in the by falls strengthened the estimated protective effect of PHTLS to 210

183 PHTLS group had more years of employment in ambulance services, OR = 0.54 (Table 2) but with poor precision (95% CI, 0.13–2.41). 211

184 compared to the non-PHTLS group (Table 1). There was no appar- A short interval from PHTLS training resulted in a stronger pro- 212

185 ent overall difference in response time, on-scene time, or transport tective association with mortality (Table 2). The precision in these 213

186 time between the two groups. estimates was poor. 214

187 3.2. Relative and absolute mortality risk 3.4. Characteristics of excluded patients 215

188 The mortality was 4.7% (36/763) without PHTLS training and There were no major differences in age, sex, cause of injury, 216

189 4.5% (94/2067) with PHTLS training. The crude (unadjusted) odds injury severity, major organs injured, or mortality when charac- 217

190 ratio (OR) for mortality was 0.96 [95% confidence interval (CI), teristics among the excluded cases were compared to the study 218

191 0.66–1.44]. The adjusted OR for mortality was 0.71 (95% CI, population (supplementary data: table* 3). In electronic EMS 219

Please cite this article in press as: Johansson J, et al. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on
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B. PHTLS trained present A. Highest educational level present

100

100
80

80
Proportion of injury events (%)
Proportion of injury events (%)
60

60
40

40
At least one with PHTLS Registered nurse
No one with PHTLS EMT equivalent
20

20
0

0
1998 2000 2002 2004 1998 2000 2002 2004

Fig. 2. Change during the study period in the distribution of highest educational level in the ambulance crews (left panel) and the proportion of injury events where at least
one PHTLS-trained individual was present (right panel). EMT equivalent, Emergency Medical Technician equivalent (nursing assistants with special ambulance training).

Table 1
Baseline characteristics of the Study Cohort.

N At least one member of the ambulance No member of the ambulance

crew with PHTLS certification crew with PHTLS certification
(N = 2067) (N = 763)

Age, % (N) 2830

0–14 2 (39) 1 (9)
15–24 4 (93) 5 (37)
25–44 11 (219) 10 (78)
45–64 18 (362) 11 (86)
65–74 11 (220) 11 (85)
≥75 55 (1134) 61 (468)
Sex, % (N) 2830
Male 37 (759) 38 (292)
ICISS stratified, % (N) 2830
Critical 1 (23) 0 (2)
Severe 1 (20) 1 (7)
Serious 5 (96) 4 (30)
Moderate 48 (1000) 50 (379)
Minor 45 (928) 45 (345)
Head injury, % (N) 2830 9 (194) 9 (71)
Spinal cord injury, % (N) 2830 0 (6) 0 (0)
Thoracic injury, % (N) 2830 6 (122) 6 (42)
Abdominal injury, % (N) 2830 1 (27) 1 (7)
Pelvic injury, % (N) 2830 6 (118) 6 (46)
No. of major injury regions, % (N) 2830
None 80 (1653) 80 (612)
One 18 (372) 18 (140)
Two 2 (33) 1 (7)
Three or more 0 (9) 1 (4)
Cause of injury, % (N) 2830
Fall 76 (1570) 80 (607)
Traffic 11 (234) 9 (71)
Other 13 (263) 11 (85)
Highest crew member education, % (N) 2830
EMT equivalent 32 (660) 75 (574)
Registered nurse 68 (1407) 24 (189)
Shortest interval from PHTLS training in the 2067 1.4 (0.7–2.3) NA
ambulance crew (years), median (IQR)
Maximum years of individual experience in EMS, 2830 18 (15–22) 16 (12 to 19)
median (IQR)
Response time minutes, median (IQR) 2563 9 (5–15) 9 (5–15)
On-scene time minutes, median (IQR) 2497 11 (8–16) 10 (7–14)
Transport time minutes, median (IQR) 2059 11 (7–25) 12 (7–24)
Prehospital mortality, % (N) 2830 1% (20) 0% (2)
Hospital mortality, % (N) 2830 4% (74) 4% (34)

ICISS, International Classification of disease Injury Severity Score; IQR, interquartile range; EMS, Emergency Medical Service; EMT, Emergency Medical Technician.

Please cite this article in press as: Johansson J, et al. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on
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Table 2
Complementary analysesa , using subgroups and graded exposures, of the association between PHTLS certification and mortality.

Subgroup Number of patients Number of deaths Crude (unadjusted) Adjusted OR (95%

(no PHTLS/PHTLS) (no PHTLS/PHTLS) OR (95% CI) CI)

Traffic and other injury, excluding falls 156/497 7/29 1.32 (0.60–3.33) 0.54 (0.13–2.41)
Effect-measure modification by injury severity
More severe injury (ICISS < 0.665) 39/139 9/35 1.12 (0.50–2.71) 0.80 (0.20–3.44)
Less severe injury (ICISS ≥ 0.665) 724/1928 27/59 0.81 (0.52–1.31) 0.77 (0.28–2.04)
Length of the interval since PHTLS certification 763/2067 36/94
(shortest in the ambulance crew)
≤1 year 0.75 (0.44–1.24) 0.66 (0.36–1.20)
>1 year 1.09 (0.72–1.66) 0.76 (0.42–1.41)

OR, odds ratio; CI, confidence interval; ICISS, International Classification of disease Injury Severity Score.
a
Multivariable logistic regression model also included age, sex, injury severity (ICISS), cause of injury (all transport/fall/other), study year, head injury, spinal cord injury,
thoracic injury, abdominal injury, pelvic injury, and years of employment in ambulance service.

220 patient care reports without a valid personal identification num- biased estimates of variance. However, methods that do not uti- 267

221 ber for the patient, the median RTS was 8, identical to the median lize all available data may be inefficient. Analytically accounting 268

222 RTS among those with a complete personal identification number. for these showed that their impact on the estimated associations 269

223 Multiple imputation of the major offending variables – PHTLS status was minimal. 270

224 and employment time – did not substantially change the estimated Despite good control of several important confounders, limited 271

225 association or the precision in the estimate (supplementary data: causal inference can be made from a single observational study. 272

226 table* 4). Largely due to the relatively low overall mortality in our study, the 273

precision of our estimates was low. 274

We can only speculate why PHTLS training appeared to be asso- 275

227 4. Discussion ciated with reduced mortality after trauma. According to the PHTLS 276

concept, endotracheal intubation is the preferred method of air- 277

228 This population-based observational study indicates that PHTLS way control, although several studies dispute the benefits of this 278

229 training of ambulance crew members may be associated with procedure.36–38 In our study, no member of the ambulance crew 279

230 approximately 30% relative reduction of mortality in trauma vic- was authorized to perform endotracheal intubation on trauma 280

231 tims. However, with the low overall mortality in this population, patients, irrespective of PHTLS training. Thus, acquisition of this 281

232 the precision of this estimate was low making the interpretation specific airway management skill could not explain the lowered 282

233 of this possible association difficult. The predicted absolute risk mortality seen in our study. In fact, in this EMS system, ALS inter- 283

234 reduction is estimated to correspond to 0.5 lives saved annually per ventions related to PHTLS had already been implemented before 284

235 100,000 population with PHTLS fully implemented.Despite decades PHTLS education, with the exception of endotracheal intubation. 285

236 of widespread implementation of educational programs such as Therefore, the observed association between PHTLS education and 286

237 ATLS and PHTLS, there is scant scientific evidence for beneficial reduced mortality was most likely not due to the application of 287

238 effects in trauma outcome.6,7,12 Today, a substantial proportion of individual ALS interventions. 288

239 ambulance crews include an ALS-trained member.31 While there It has been demonstrated that PHTLS training improves adher- 289

240 are studies on conditions other than trauma indicating that ALS ence to established priorities and management of the trauma victim 290

241 training and higher educational levels among ambulance crews in a structured approach, which could possibly shorten time to 291

242 improves outcomes,32,33 there is little support for such an asso- definitive care.12,39 In our study though, response time, on-scene 292

243 ciation in trauma care.34–36 time, and transport time did not appear influenced by PHTLS train- 293

244 Three conditions provided a rare opportunity to perform a com- ing. The impact of the structured approach, including assessment 294

245 prehensive observational study of the association between PHTLS and setting priorities that the PHTLS concept is focused on, is dif- 295

246 training and outcome: (a) the introduction of prehospital electronic ficult to measure and could possibly explain the association with 296

247 medical records, (b) the subsequent gradual implementation of reduced mortality. 297

248 PHTLS, and (c) exact record linkage of patient injury data in national The percentage of ambulance crews trained in PHTLS went from 298

249 healthcare databases. We could associate each injury case with approximately 15% to almost 90% in a relatively short time period. 299

250 the educational level of the ambulance crew and adjust for each This focused educational effort could possibly create a Hawthorne- 300

251 crew’s years of experience and basic educational level. We further like effect, making the PHTLS-trained personnel particularly prone 301

252 controlled for injury cause, type and severity, and also the year to perform better in general, regardless of the content of the 302

253 of the study in which the exposure/incident occurred in order to course. However, the implementation of PHTLS in the organiza- 303

254 account for a possible period effect. The population-based design tion could possibly also have influenced ambulance crew members 304

255 and good control of confounding – and especially a potential period not trained in PHTLS in a positive direction, thus also improving 305

256 effect – support the findings in this study. Exclusion of observations outcome in the control group. 306

257 with incomplete data was unfortunate; however, the comparable Concerning the ability to generalize our results to other set- 307

258 characteristics of these patients to the study population, the small tings, it is notable that the PHTLS course is highly standardized. 308

259 impact on the estimated association from imputation of missing However, the basic educational level of prehospital crews varies 309

260 values, and the absence of apparent effect-measure modification between organizations and therefore other results could possibly 310

261 from injury severity did not raise any grave concern of a selection be achieved in a similar study in another setting such as a paramedic 311

262 bias. or EMT-based system. The study population represents the popu- 312

263 A particular challenge for this type of study is that the same lation admitted to a general hospital, but is not representative of a 313

264 ambulance crews appear several times in the data, and similarly selected trauma-center population. This is reflected by the female 314

265 a patient may also present repeated times. Ignoring such correla- dominance and large number of falls causing minor or moderate 315

266 tions within the data may lead to incorrect statistical inference and injuries. 316

Please cite this article in press as: Johansson J, et al. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on
survival of trauma victims. Resuscitation (2012), doi:10.1016/j.resuscitation.2012.02.018
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317 Excluding falls from the study population, i.e. mainly elderly 8. Drimousis PG, Theodorou D, Toutouzas K, et al. Advanced trauma life support 364

318 patients with hip fractures, as expected strengthened the asso- certified physicians in a non trauma system setting: is it enough? Resuscitation 365
2011;82:180–4. 366
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and health related problems icd-10. Geneva: World Health Organization; 2005. 379
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Please cite this article in press as: Johansson J, et al. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on
survival of trauma victims. Resuscitation (2012), doi:10.1016/j.resuscitation.2012.02.018