Advanced Trauma Life Support certified physicians in a non trauma system setting: Is it enough?

doi:10.1016/j.resuscitation.2010.10.005

Resuscitation

Volume 82, Issue 2, February 2011, Pages 180-184

https://doi.org/10.1016/j.resuscitation.2010.10.005 Get rights and content

Abstract

Objective

The purpose of this study was to evaluate the impact of ATLS^® on trauma mortality in a non-trauma system setting. ATLS represents a fundamental element of trauma training in every trauma curriculum. Nevertheless, there are limited studies in the literature as for the impact of ATLS training in trauma mortality, especially outside the US.

Design

This is a prospective observational study. The primary end point was to investigate factors that affect mortality of trauma patients in our health care system. We performed a multivariate analysis for this purpose and we identified ATLS certification as a predictor of overall mortality. Following this finding we stratified patients according to the severity of injury as expressed by the ISS score and we compared outcome between those treated by an ATLS certified physician and those treated by non-certified ones.

Main outcome measures

Trauma volume and demographics of trauma patients, factors that affect mortality of traumatized patients and mortality between patients treated by ATLS^® certified and non-certified physicians.

Results

In total, 8862 trauma patients were included in the analysis. The majority of trauma patients (5988, 67.6%) were treated by a general surgeon, followed by those treated by an orthopedic surgeon (2194, 24.8%). There were 446 deaths in the registry but, 260 arrived dead in the Emergency Department and were excluded from the analysis. Multivariate analysis of the 186 deaths that occurred in the hospital revealed age, high ISS score, low GCS score, urban location of injury, neck injury and ATLS^® certification as factors predisposing to mortality. Cross tabulation of ATLS^® certification and ISS of the trauma patients shows that those treated by certified physicians died more often in all subcategories of ISS score (p < 0.05).

Conclusions

In Greece, with no formal trauma system implementation, ATLS^® certified physicians achieve worse outcomes than their non-certified colleagues when managing trauma patients. We believe that these findings must be interpreted in the context of the National health care system. There is considerable room for improvement in our country, and further analysis is required.

Section snippets

Objective

Advanced Trauma Life Support (ATLS^®) course was developed by the American College of Surgeons following the tragic event of an orthopedic surgeon piloting his plane, who crashed into a Nebraska cornfield with his family, causing severe injuries to his 3 children and the death of his wife. Insufficiency in the system was noted by the care delivered at the primary care facility, leading to a call for a systems change that begun in Nebraska and in 1978 the first ATLS^® course was held.¹ For over

Setting

This study was held in a twelve months period between October 2005 and October 2006. Data presented are derived retrospectively from a countrywide trauma registry entitled “Report of the Epidemiology and Management of Trauma in Greece”. The registry is a project initiated by the Hellenic Society of Trauma and Emergency Surgery and it represents an effort to record and evaluate the epidemiology of trauma in Greece and to critically assess the management of trauma patients in the country. The

Results

In total, thirty hospitals participated in the study and 8.862 trauma patients were enrolled. Of them 6084 (68.7%) were male, aged 41.8 ± 20.6 (Mean ± SD) and 2778 were female (31.3%), aged 52.7 ± 24.1 (Mean ± SD). Fig. 1 shows a map of the country and the participating hospitals.

The specialty of the receiving physician is shown in Table 1. The majority of trauma patients (5988, 67.6%) were treated by a general surgeon, followed by those treated by an orthopedic surgeon (2194, 24.8%). Table 2 presents

Comment

Concerns over the value of ATLS^® in particular outside the US are not novel.7, 8 As early as 1979 Sims⁹ commented that the educational benefit of trauma laboratory training as determined by formal educational testing had yet to be established. Later on, Girroti¹⁰ raised a question whether the ATLS^® course made a difference to trauma care. More recently, there are voices that the North-American principles are not applicable in Europe and that the development of a European alternative course may

Conclusions

In our country, with no formal trauma system implementation, data suggest that ATLS^® certified physicians achieve worse outcomes than their non-certified colleagues when managing trauma patients. Obviously, the way the course is applied in clinical practice in our country needs reassessment. There is little doubt that ATLS^® is a fundamental part of trauma care. However, just as trauma does not respect the borders of organ systems or medical disciplines, training for the complex management of

Conflict of interest

The authors declare no conflict of interest for this work.

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Cited by (19)

Does ATLS Training Work? 10-Year Follow-Up of ATLS India Program
2021, Journal of the American College of Surgeons
Citation Excerpt :
We found that the knowledge attrition was the least among ATLS instructors, as has been reported in other studies too and for obvious reasons.16 The attrition of knowledge and skills gained in ATLS has been reported to start after 6 months; organizational lessons tend to be retained the longest, in some reports up to 8 years.17 We found longer retention of the benefits of ATLS in our cohort than in the published literature.
Studies evaluating the efficacy of ATLS in low- and middle-income countries are limited. We followed up ATLS providers certified by the ATLS India program over a decade (2009 to 2019), aiming to measure the benefits in knowledge, skills, attitude and their attrition over time.
The survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email as a Google form, along with a statement of purpose. Results are presented descriptively.
ATLS India trained 7,847 providers over the study period. 2500 providers were selected for the survery using computer-generated random number table. One thousand and thirty doctors (41.2%) responded. Improvement in knowledge (n = 1,013 [98.3%]), psychomotor skills (n = 986 [95.7%]), organizational skills (n = 998 [96.9%]), overall trauma management (n = 1,013 [98.7%]) and self-confidence (n = 939 [91%]) were reported. Majority (904 [87.8%]) started ATLS promulgation at workplace in personal capacity. These benefits lasted beyond 2 years in majority (>60%) of respondents. More than 40% reported cognitive (n = 492 [47.8%]), psychomotor (n = 433 [42%]), and organizational benefits (n = 499 [48.4%]) lasting beyond 3 years. Improvement in self-confidence, ATLS promulgation at the workplace, and retention of organizational skills were more pronounced in ATLS faculties than providers. All other benefits were found to be comparable in both sub-groups. Lack of trained staff (n = 660 [64.1%]) and attitude issues (n = 495 [48.1%]) were the major impediments in implementing ATLS at the workplace. More than a third of respondents (n = 373 [36.2%]) could enumerate one or more incidents where ATLS principles were life- or limb- saving.
Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Until formal trauma systems are established, ATLS remains the best hope for critically injured patients in resource-contrained settings.
Trauma system in Greece: Quo Vadis?
2018, Injury
Citation Excerpt :
Furthermore, the clear majority of trauma patients in small and secondary hospitals are managed by a general surgery resident in the ED, plus a nurse, due to limits in resources and personnel [43]. As national health care planning does not include Trauma Surgery as a distinct subspecialty, the burden of trauma is being transferred to general surgeons [43,44]. Current planning doesn’t include Emergency physicians either, as EDs are not autonomously working, but are rather one station of the institution, “borrowing” different physicians from clinics of each subspecialty on 24-hour calls [42].
Implementation of trauma systems has markedly assisted in improving outcomes of the injured patient. However, differences exist internationally as diverse social factors, economic conditions and national particularities are placing obstacles. The purpose of this paper is to critically evaluate the current Greek trauma system, provide a comprehensive review and suggest key actions.
An exhaustive search of the – scarce on this subject – English and Greek literature was carried out to analyze all the main components of the Greek trauma system, according to American College of Surgeons’ criteria, as well as the WHO Trauma Systems Maturity Index.
Regarding prevention, efforts are in the right direction lowering the road traffic incidents-related death rate, however rural and insular regions remain behind. Hellenic Emergency Medical Service (EKAB) has well-defined communications and emergency phone line but faces problems with educating people on how to use it properly. In addition, equal and systematic training of ambulance personnel is a challenge, with the lack of pre-hospital registry and EMS quality assessment posing a question on where the related services are currently standing. Redistribution of facilities’ roles with the establishment of the first formal trauma centre in the existing infrastructure would facilitate the development of a national registry and introduction of the trauma surgeon subspecialty with proper training potential. Definite rehabilitation institutional protocols that include both inpatient and outpatient care are needed. Disaster preparedness entails an extensive national plan and regular drills, mainly at the pre-hospital level. The lack, however, of any accompanying quality assurance programs hampers the effort to yield the desirable results.
Despite recent economic crisis in Greece, actions solving logistics and organising issues may offer a well-defined, integrated trauma system without uncontrollably raising the costs. Political will is needed for reforms that use pre-existing infrastructure and working power in a more efficient way, with a first line priority being the establishment of the first major trauma centre that could function as the cornerstone for the building of the Greek trauma system.
Prehospital trauma life support training of ambulance caregivers and the outcomes of traffic-injury victims in Sweden
2013, Journal of the American College of Surgeons
There is limited evidence that the widely implemented Prehospital Trauma Life Support (PHTLS) educational program improves patient outcomes. The primary aim of this national study in Sweden was to investigate the association between regional implementation of PHTLS training and mortality after traffic injuries.
We extracted information from the Swedish National Patient Registry and the Cause of Death Registry on victims of motor-vehicle traffic injuries in Sweden from 2001 to 2004 (N = 28,041). During this time period, PHTLS training was implemented at a varying pace in different regions. To control for other influences on patient outcomes related to regional and hospital-level effects, such as variations in performance of trauma care systems, we used Bayesian hierarchical regression models to estimate odds ratios for prehospital mortality and 30-day mortality after hospital admission. We also controlled for the calendar year for each injury to account for period effects. We analyzed the time to death after hospital admission and time to return to work using Cox's proportional hazards frailty models.
After multivariable adjustment, the odds ratio for prehospital mortality with PHTLS-trained prehospital staff was 1.54 (95% credibility interval, 1.07–2.13). For 30-day mortality among those surviving to hospital admission, the odds ratio was 0.85 (95% credibility interval, 0.45–1.48). There was no association between PHTLS training and time to death (hazard ratio = 0.99; 95% CI, 0.85−1.14) or time to return to work (hazard ratio = 0.98; 95% CI, 0.92−1.05).
In this observational study, the implementation of PHTLS training did not appear to be associated with reduced mortality or ability to return to work after motor-vehicle traffic injuries.
Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims
2012, Resuscitation
Citation Excerpt :
Although implemented worldwide, there is still no strong evidence that ATLS lowers mortality in trauma victims.6,7 According to a recent study, ATLS-training might even impair outcome.8 The Prehospital Trauma Life Support (PHTLS) program was introduced in 1983 to integrate prehospital trauma care with the ATLS program.9
The Prehospital Trauma Life Support (PHTLS) course has been widely implemented and approximately half a million prehospital caregivers in over 50 countries have taken this course. Still, the effect on injury outcome remains to be established. The objective of this study was to investigate the association between PHTLS training of ambulance crew members and the mortality in trauma patients.
A population-based observational study of 2830 injured patients, who either died or were hospitalized for more than 24 h, was performed during gradual implementation of PHTLS in Uppsala County in Sweden between 1998 and 2004. Prehospital patient records were linked to hospital-discharge records, cause-of-death records, and information on PHTLS training and the educational level of ambulance crews. The main outcome measure was death, on scene or in hospital.
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.
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.
TEAM: A Low-Cost Alternative to ATLS for Providing Trauma Care Teaching in Haiti
2018, Journal of Surgical Education
Citation Excerpt :
Since its introduction to the health care community, the Advanced Trauma Life Support (ATLS) protocol had a significant impact on delivery of trauma care with notable reductions in mortality, particularly in high-income countries.4–7 Following its success in high-income countries, ATLS has been introduced to the global health community and has been delivered to over one million providers in more than 60 countries.8,9 However, as the ATLS is designed for areas with access to ample medical resources, there is debate whether the course’s success is transferable to LMIC.10,11
Trauma resuscitation protocols have unified the care of trauma patients and significantly improved outcomes. However, the success of the Advanced Trauma Life Support course is difficult to reproduce in developing countries due to set-up costs, limitations of resources, and variations of practice. The objective of this study is to assess the Trauma Evaluation and Management (TEAM) course as a low-cost alternative for trauma resuscitation teaching in Low and Middle Income Countries (LMIC).
As part of the Team Broken Earth initiative, TEAM course was provided to the health care professionals in Haiti. At its conclusion, participants were asked to complete a survey evaluating the course. Qualitative and quantitative data were analyzed to evaluate the perception of the course.
The course was provided in Port-au-Prince, Haiti.
A total of 80 health care professionals participated in the course. Response was obtained from 69 participants, which comprised of 32 physicians, 10 Emergency Medical Technicians (EMT), 22 nurses, and 5 medical trainees.
The course was well received by physicians, nurses, and EMT with an average score of 90.6%. Question analysis revealed a lower satisfaction of physicians for the course manual and teaching materials, and information related to decisions for transfer of patients. EMT consistently felt that the course was not tailored to their learning and practice needs. Written feedback demonstrated several areas of weaknesses including need for improvements in translations, hands-on practice, and educational materials.
Overall, the TEAM course was well received. Analysis demonstrated a need for adjustments specific to LMIC including a focus on prehospital assessment, increased nursing responsibilities, and unavailability of specialist’s referrals. Team Broken Earth intends to take these findings into consideration and continue to provide the TEAM course to other LMIC.
Orthopaedic and trauma care in low-resource settings: the burden and its challenges
2022, International Orthopaedics

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2010.10.005.

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Clinical paperAdvanced Trauma Life Support certified physicians in a non trauma system setting: Is it enough?☆

Abstract

Objective

Design

Main outcome measures

Results

Conclusions

Section snippets

Objective

Setting

Results

Comment

Conclusions

Conflict of interest

Surgeon

Injury

Resuscitation

Ann Emerg Med

Am J Emerg Med

J Emerg Med

Three decades (1978–2008) of Advanced Trauma Life Support (ATLS™) practice revised and evidence revisited

Scand J Trauma Resusc Emerg Med

Impact of advanced trauma life support training on early trauma management

Am J Surg

Interfacility transfers in a non-trauma system setting: an assessment of the Greek reality

Scand J Trauma Resusc Emerg Med

The implementation of a national trauma registry in Greece. Methodology and preliminary results

J Trauma

Clinical paper
Advanced Trauma Life Support certified physicians in a non trauma system setting: Is it enough?☆