Advanced training in trauma life support for ambulance crews

Injury is one of the top ten causes of death and disability worldwide. It results in an early loss of life for many young people and ongoing high medical care costs among survivors. Advanced life support (ALS) training for ambulance crews with emphasis on trauma is believed to have contributed to a reduction in the number of deaths from injury in predominantly high-income countries where this service is available. ALS services are also being adapted for low- and middle-income countries. This review of trials found there is no evidence to suggest that ALS training for ambulance personnel improves the outcomes for injured people.

Authors' conclusions: 

At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews on patient outcomes.

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Background: 

There is an increasing global burden of injury especially in low- and middle-income countries (LMICs). To address this, models of trauma care initially developed in high income countries are being adopted in LMIC settings. In particular, ambulance crews with advanced life support (ALS) training are being promoted in LMICs as a strategy for improving outcomes for victims of trauma. However, there is controversy as to the effectiveness of this health service intervention and the evidence has yet to be rigorously appraised.

Objectives: 

To quantify the impact of ALS-trained ambulance crews versus crews without ALS training on reducing mortality and morbidity in trauma patients.

Search strategy: 

The search for studies was run on the 16th May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), PubMed and screened reference lists.

Selection criteria: 

Randomised controlled trials, controlled trials and non-randomised studies, including before-and-after studies and interrupted time series studies, comparing the impact of ALS-trained ambulance crews versus crews without ALS training on the reduction of mortality and morbidity in trauma patients.

Data collection and analysis: 

Two review authors assessed study reports against the inclusion criteria, and extracted data.

Main results: 

We found one controlled before-and-after trial, one uncontrolled before-and-after study, and one randomised controlled trial that met the inclusion criteria. None demonstrated evidence to support ALS training for pre-hospital personnel. In the uncontrolled before-and-after study, 'a priori' sub-group analysis showed an increase in mortality among patients who had a Glasgow Coma Scale score of less than nine and received care from ALS trained ambulance crews. Additionally, when the pre-hospital trauma score was taken into account in logistic regression analysis, mortality in the patients receiving care from ALS trained crews increased significantly.

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