Effect of Physician-Staffed Emergency Medical Services (P-EMS) on the Outcome of Patients with Severe Traumatic Brain Injury: A Review of the Literature

Abstract

Introduction: Traumatic injury is the fourth leading cause of death in western countries and the leading cause of death in younger age. However, it is still unclear which groups of patients benefit most from advanced prehospital trauma care. A minimal amount is known about the effect of prehospital physician-based care on patients with specifically traumatic brain injury (TBI). The aim of this review is to assess the effect of physician-staffed Emergency Medical Services (EMS) on the outcome of patients with severe TBI. Methods: Literature searches have been performed in the bibliographic databases of PubMed, EMBASE and The Cochrane Library. Data concerning (physician-staffed) prehospital care for patients with severe TBI were only included if the control group was based on non-physician-staffed EMS. Primarily the mortality rate and secondarily the neurological outcome were examined. Additionally, data concerning hypotension, hypoxia, length of stay (hospital and intensive care unit) and the number of required early neurosurgical interventions were taken into account. Results: The overall mortality was decreased in three of the fourteen included studies after the implementation of a physician in the prehospital setting. One study found also a decrease in mortality only for patients with a Glasgow Coma Scale of 6-8. Strikingly, two other studies reported higher mortality, one for all the included patients and one for patients with GCS 10-12 only. Neurological outcome was improved in five studies after prehospital deployment of a physician. One study reported that more patients had a poor neurological outcome in the P-EMS group. Results of the remaining outcome measures differed widely. Conclusion: The included literature did not show a clear beneficial effect of P-EMS in the prehospital management of patients with severe TBI. The available evidence showed contradictory results, suggesting more research should be performed in this field with focus on decreasing heterogeneity in the compared groups.

Prehospital time and mortality in polytrauma patients: a retrospective analysis

“…Our analysis controlled for all of these factors, as well as for other potential confounders such as gender, type and mechanism of injury, and HEMS assistance. Nonetheless, residual confounding due to unobserved variables – such as hemodynamic, respiratory and physiologic parameters that are known to affect mortality in trauma patients [ 5 , 10 , 11 , 25 ]—cannot be excluded. Furthermore, excluding patients with missing or incomplete prehospital time and reporting solely on in-hospital mortality, not taking into account prehospital mortality, might have caused a certain degree of selection bias.…”

Impact of emergency physician-staffed ambulances on preoperative time course and survival among injured patients requiring emergency surgery or transarterial embolization: A retrospective cohort study at a community emergency department in Japan

“…Therefore, most Japanese tertiary medical centers, including the study site, run a hospital-based emergency physician (EP) delivery system for early initiation of advanced trauma care [12]. Nevertheless, the effect of EP deployment to the prehospital scene on outcomes among injured patients remains controversial: Several studies have shown that EP involvement in prehospital trauma care is associated with improved survival in patients with trauma [13][14][15][16][17][18][19] whereas other studies report no significant differences [20][21][22][23] or decreased survival [24]. Although injured patients requiring definitive intervention, such as surgery or TAE, are an extremely time-sensitive population, previous studies have not focused on this important trauma subset [13][14][15][16][17][18][19][20][21][22][23][24], and little is known regarding whether and how an EP delivery system affects the preoperative time course and patient survival.…”

“…Nevertheless, the effect of EP deployment to the prehospital scene on outcomes among injured patients remains controversial: Several studies have shown that EP involvement in prehospital trauma care is associated with improved survival in patients with trauma [13][14][15][16][17][18][19] whereas other studies report no significant differences [20][21][22][23] or decreased survival [24]. Although injured patients requiring definitive intervention, such as surgery or TAE, are an extremely time-sensitive population, previous studies have not focused on this important trauma subset [13][14][15][16][17][18][19][20][21][22][23][24], and little is known regarding whether and how an EP delivery system affects the preoperative time course and patient survival. Additionally, despite hospital LOS being a sensitive indicator that reflects patients' disease burden, previous studies have not clarified how EP involvement in prehospital trauma care affects this important parameter, as compared with ELSTs [13][14][15][16][17][18][19][20][21][22][23][24].…”

“…Although injured patients requiring definitive intervention, such as surgery or TAE, are an extremely time-sensitive population, previous studies have not focused on this important trauma subset [13][14][15][16][17][18][19][20][21][22][23][24], and little is known regarding whether and how an EP delivery system affects the preoperative time course and patient survival. Additionally, despite hospital LOS being a sensitive indicator that reflects patients' disease burden, previous studies have not clarified how EP involvement in prehospital trauma care affects this important parameter, as compared with ELSTs [13][14][15][16][17][18][19][20][21][22][23][24]. Because running an EP-staffed ambulance requires considerable cost as well as human resources [12,20], rigorous investigation of its effectiveness compared with that of a conventional ELST-staffed ambulance is warranted.…”

Template for documenting and reporting data in physician-staffed pre-hospital services: a consensus-based update

“…Pre-hospital physicians have the potential to restore adequate flow and physiology in severely sick or injured patients, but the subject remains debated [1][2][3][4][5][6]. P-EMS are resource demanding compared with standard paramedic-staffed services [7], and more research is needed to evaluate any potential effects of p-EMS [1,8,9]. High-quality research relies on data quality and uniform documentation is essential to ensure reliable and valid data.…”