Elsevier

Injury

Volume 38, Issue 9, September 2007, Pages 1001-1013
Injury

Emergency Medical Service (EMS) systems in developed and developing countries

https://doi.org/10.1016/j.injury.2007.04.008Get rights and content

Summary

Objectives

To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries.

Method

We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) >15 and the pre-hospital trauma care provided to these patients were compared among different countries.

Results

A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1 min) and Montreal, Canada (median 16.1 min) reported the shortest and Germany (median: 30 min) and Austria (median: 26 min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively).

Conclusion

This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.

Introduction

Infectious diseases had traditionally been the leading cause of death and disability in all nations.21 However, the mortality pattern in developed countries has changed significantly. For example in the United States, chronic diseases such as cancer and heart disease are now the leading cause of death among adults older than 44 years, while injury is the single most prominent cause of death in children and younger adults.1 This epidemiologic transition has not been restricted to developed countries, and many lesser developed nations are experiencing similar transformations in such a way that trauma is now an important cause of years of life lost in many middle-income countries.23, 35, 43, 44

In developed countries, there has been a decrease in trauma mortality in recent decades, which has been attributed to a combination of injury prevention endeavours and improvements in trauma care.3 It is generally thought that improvements in pre-hospital trauma care might decrease trauma mortality during the first few hours after injury by preventing irreversible changes that could otherwise lead to death.12, 33 Pre-hospital care might also decrease long-term mortality and morbidity from trauma.12, 33, 38 Therefore, addressing deficiencies in pre-hospital care represents one mechanism to improve the outcome of critically injured patients.

From an international perspective, the delivery of pre-hospital care falls into one of four categories. In “unorganised pre-hospital care”, which exists in most of the developing world, there is no formal system to provide pre-hospital care in the field, and patients are transported to medical care facilities by law enforcement personnel especially in violent situations,6 private or public vehicles, motorcycles, wheelbarrows or other means. In Basic Life Support (BLS) Emergency Medical Service (EMS) systems, Emergency Medical Technicians (EMTs) provide non-invasive basic care to trauma patients. The major focus of EMTs in this context is rapid transport of trauma patients to a medical facility. Many small cities and rural areas are served by this type of system in high- and middle-income countries. Advance Life Support (ALS) EMS systems provide more sophisticated and invasive therapy, such as intravenous (IV) fluid therapy and endotracheal intubation. Lastly, in some environments, physicians go to the scene of injury (Doc-ALS EMS systems), and are responsible for providing advanced care to trauma victims at the scene and during transport.

Given the recent emphasis on developing pre-hospital trauma care globally33 and as the first step in evaluating outcomes related to pre-hospital care, we set out to describe the settings, the spectrum of injury and the process of pre-hospital care in one or several regions across 11 developed and developing countries. These regions might not be representative of the whole country. However, with the exception of “unorganised” or no pre-hospital care, they represent the continuum of pre-hospital care described above.

Section snippets

Source of data

We collated de-identified patient-level data from either regional trauma registries (in Australia, Austria, Canada, Greece, Germany, New Zealand, the Netherlands, the United Kingdom, the United States) or databases developed expressively for the purpose of evaluating either pre-hospital2 or hospital care research14, 41 (in Mexico, Iran). Data were obtained from either regional authorities and/or contributed by the investigators. We chose these settings to exemplify EMS care in a spectrum of

Results

A total of 30,175 patients from 11 countries were included. Iran with 130 patients and Germany with 9688 patients had the smallest and the largest number of subjects, respectively. Table 3 summarises the demographic and injury-related characteristics of the patients.

On average, 73% of the patients were male. Iran had the highest proportion of male patients (82%) and Mexico reported the lowest proportion (67%). Mexico (mean age: 28 years; S.D.: 16) and Iran (mean age: 31 years; S.D.: 19) had the

Discussion

This study allowed us to compare injury-related characteristics of the patients and pre-hospital features of the EMS systems among 11 developed and developing countries. Before discussing the main findings, we would like to address the main limitations of the study. First, we used local or national trauma registries of the collaborating countries. These trauma registries might not be representative of the universe of trauma patients or the pre-hospital trauma care experience in these countries.

Conclusion

This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients. This standardised data set could eventually be promoted worldwide, with standardised definitions accompanying it. This would facilitate and extend future international pre-hospital trauma care collaborative research projects.

Acknowledgements

The authors would like to thank the following individuals and organisations for their invaluable support throughout this research project: Christopher Mack, Steve Bowman, Victorian State Trauma Registry (Australia), The Quebec Trauma Registry (Canada), German Trauma Registry and German Society of Trauma Surgery (Germany, Austria and the Netherlands), Centre for Research and Prevention of Injuries (Greece), Sina Trauma Research Centre (Iran), Nuevo Leon EMS system (Mexico), Auckland City

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