The present study is a controlled field trial and conducted to investigate the effect of the PHTLS program on the on-scene time in pre-hospital emergency services in 2019 (July 23 till August 30). The PHTLS program is a standard curriculum for pre-hospital care providers. The published articles by Emergency Medical Consultants, Inc. on care of trauma victims in pre-hospital emergencies, and the National Association of Emergency Medical Technicians website were used to design the structure, content, and scheduling of theoretical (lectures) and practical sessions (skill stations).
The theoretical part was conducted through classical methods (slides and educational videos). The first day included course introduction, scene review and initial assessment, airway management, respiration, ventilation and oxygenation, bleeding, shock and disabilities. The second day involved group discussion and review of first-day topics, secondary assessment, trauma in children and the elderly, burn, triage and cardiopulmonary resuscitation in trauma patients. Practical sessions were performed via clinical simulation method in trauma stations and in accordance with standard scenarios of the PHTLS program in trauma victims. This embraced overturning of car and throwing of the careless driver from the vehicle, second station of seizures and head trauma at home, quarrel and stabbing in a homeless camp in the city’s outskirts, traumatic brain injury and so forth. Furthermore, at this stage, in addition to the scene assessment and initial assessment techniques, instructions based on the ABCDE approach and scenario-based training were also given.
One trained instructor and one stimulated patient were used for each station, and in all stations, checklists were used to evaluate technicians and the instructors gave the necessary feedback. The sessions lasted between 20 and 160 min (a total of 16 h) over two days [11, 15,16,17,18]. All methods were carried out in accordance with relevant guidelines and regulations.
Study area and population
This study was performed in the Pre-hospital Emergency Center of Gonabad, in the east of Iran. The strategic location and feasibility of the Gonabad Emergency Center makes it a particularly suitable center for providing pre-hospital services to trauma victims in the northeastern region of the country. The Gonabad Emergency Center received 55,939 calls in 2018, of which 14,190 resulted in dispatch. In total, 3464 of these dispatches were related to trauma missions. The calls that did not result in dispatch included repeated calls, non-emergency calls, failed calls, harassment, and counseling.
Sampling was done in three stages through convenient, stratified and then simple random allocation. To do so, 64 technicians who met the inclusion criteria were selected via convenient sampling and divided into two categories (Associate degree and B.A). Then, samples from each level were randomly divided into experimental and control groups according to the number of technicians. It should be noted that four people in the control group were excluded from the study due to the lack of registered cases of eligible trauma victims for each technician within the specified time (See Fig. 1). Instances of trauma and on-scene time were extracted from the standard intervals of emergency services. Trauma cases were selected based on the classification of the causes of injuries based on an expanded matrix of the US Centers for Disease Control and Prevention. Consequently, trauma cases were divided into three categories: road traffic injuries, falls and other types of injuries .
The on-scene time interval was assessed and calculated based on the standard intervals of providing emergency services (See Table 1).
The inclusion criteria included no history of participation in the life preservation course in trauma victims, and filling the standard pre-hospital emergency care questionnaire for trauma victims who were injured and transported to the medical center by an ambulance. To achieve the average on-scene time, at least three trauma missions were extracted in three stages including time intervals before, after and one month after the intervention for each technician according to the study group (the duration of each time interval was one week and extended to two weeks if not reached the limit). To control for the confounding variables that may affect the on-scene time, only missions that required emergency medical operations were included in the study. As such missions that contained an unsafe scenes where the technicians were on hold due to scene conditions or required release (e.g. trapped patients) prior to emergency medical operations were excluded from the study.Thus, a total of 526 electronic emergency contact records that met the inclusion criteria were documented (experimental group = 272 cases; control group = 254 cases).
A questionnaire was used to collect the data. The first part gathered the demographic information including age, level of education and work experience of technicians, which was completed via self-report. The second part was a standard questionnaire designed by the Ministry of Health and Medical Education in Iran. It contains electronic demographic characteristics of patients, the initial diagnosis of the disease and causes of crashes, and times of emergency service delivery. Timing includes the mission announcement time, moving from the base, reaching the emergency location, leaving the emergency location, reaching the medical center, delivery to the medical center, leaving the medical center and the end of the mission time .
Kolmogorov–Smirnov test showed that the variables are distributed normally. An independent t-test was used to compare the on-scene time interval in the experimental and control groups before and after the intervention. To compare the trend of changes in on-scene time intervals, a repeated measures ANOVA was run at the statistical level of α = 0.05. Data analysis was performed using SPSS software version 13.00 (SPSS Inc, Chicago, IL, USA).