Severely injured patients are more likely to survive if they are initially treated by an emergency medical services (EMS) clinician who sees a high number of trauma patients, rather than a clinician in a quieter area even if they have been on the job longer, new research by UPMC and University of Pittsburgh surgeon-scientists reveals.
Published today in JAMA Surgery, the findings are the first to show that the number of trauma patients treated at the EMS clinician level - not just at the hospital or agency level - is associated with improved survival and point to concrete, innovative approaches to improve EMS performance and save lives.
"EMS clinicians are the entry point into the trauma system," said senior author Joshua Brown, M.D., M.Sc., UPMC trauma surgeon and Samuel P. Harbison Endowed Assistant Professor of Surgery at the University of Pittsburgh School of Medicine. "Until a patient reaches the hospital, the paramedic or flight nurse is often the only health care provider they have. Unlike in a trauma center, there is no safety net, so it is incredibly important that they be at the top of their game."
The research builds on a previous study in the Annals of Surgery that used national data to find that EMS agencies with higher trauma volumes had better patient outcomes.
To drill down further, Brown and his colleagues paired data from the City of Pittsburgh's Bureau of EMS and STAT MedEvac with outcomes from the Linking Investigations in Trauma and Emergency Services (LITES) research network. UPMC clinicians provide clinical leadership to both agencies and the health system recently donated $10 million to the city to purchase new ambulances.
The team reviewed results for 3,649 severely injured trauma patients treated by 359 EMS clinicians between 2017 and 2021. For every five additional patients an EMS clinician saw each year, there was a 10% decrease in the risk of mortality within six hours of their injury.
Interestingly, the number of years an EMS clinician had worked was not associated with any change in patient survival.
"You might assume that someone who's been a paramedic for 20 years would automatically have better outcomes," Brown said. "But what we found is that trauma is different. Seeing more trauma patients more often - recognizing those patterns and making those high-stakes decisions - really matters."
Unlike some conditions where EMS interventions can be more straightforward - giving medications and monitoring - traumas can present in complicated ways with severe bleeding or head injury. And they often involve much more invasive interventions, such as intubating the patient or inserting a large needle into their chest wall.
"Getting EMS clinicians more exposure to traumas seems to be the key, but we can't just close EMS agencies and concentrate all the experience in one place - that would lead to longer wait times and worse outcomes," Brown said. "We need different solutions."
Potential strategies include:
- Developing national EMS quality benchmarking programs similar to those used by trauma centers
- Using artificial intelligence to help build staffing models that avoid pairing low-volume EMS clinicians together
- Expanding simulation, virtual reality and other training tools to supplement real-world experience
- Creating mentorship partnerships between high- and low-volume EMS agencies
Patients and community members can also play a role by supporting EMS systems, which are usually run through municipal government.
"Supporting EMS funding, training and innovation at the community and policy level is how our findings translate into saved lives," said Brown.
Additional authors on this research are Jamison Beiringer, M.D., Christian Martin-Gill, M.D., M.P.H., David S. Silver, M.D., M.P.H., Jason L. Sperry, M.D., M.P.H., Liling Lu, M.S., Francis X. Guyette, M.D., Stephen Wisniewski, Ph.D., all of Pitt; Ernest E. Moore, M.D., of the Ernest E. Moore Shock Trauma Center at Denver Health; Martin Schreiber, M.D., of the Uniformed Services University; Bellal Joseph, M.D., of the University of Arizona; Chad T. Wilson, M.D., of Baylor College of Medicine; Bryan Cotton, M.D., Erin E. Fox, Ph.D., and Daniel Ostermayer, M.D., all of the University of Texas Health Science Center; Brian G. Harbrecht, M.D., of the University of Louisville; and Mayur Patel, M.D., of the Vanderbilt Trauma Center.
This research was funded by American College of Surgeons C. James Carrico Faculty Research Fellowship, the LITES Task Order 1 supported by Department of Defense grant W81XWH-16-R-0033 and the U.S. Army Medical Research Acquisition Activity under contract W81XWH-16-D-0024-0001.
