This systematic review conducted in 2013 is an interesting read for anyone involved, or wishing to be involved, in the pre-hospital care of critically injured patients and the emerging role of UK critical care paramedics (CCPs) in the delivery of advanced level skills in this subset of patients.
The authors searched four large electronic databases (CENTRAL, EMBASE, MEDLINE, Web of Science) without language limitation for relevant papers from 1990 to January 2013 (date restriction not applied to hand searches); a detailed search history is included in the paper which is a useful adjunct for the reader.
The authors identified 3 871 titles, with 609 of these being considered as potentially relevant. Ultimately, after further review processes, a total of 12 papers were deemed eligible for inclusion in this review, including one randomised controlled trial, 10 retrospective cohort studies, and one quasi-randomised cohort study. The papers were appraised using the Oxford Centre of Evidence-based Medicine guidelines.
The authors compared CCP versus physician (four studies) and non-physician (four studies) led care, as well as additional skills for CCPs (three studies), drawing some interesting conclusions that allude to the difficulties in collating often disparate studies with heterogeneous methodology, patient groups and outcome measures. In particular, it was noted that a lack of randomised studies may limit the findings of the paper and as such a narrative analysis was undertaken.
‘It is refreshing to see a more balanced, less adversarial and critical appraisal of some of the issues in pre-hospital trauma care’
Moreover the paper appears to support generally emergent themes in the arena of the pre-hospital polytrauma patient; principally that this subset of patients typically require specialist care at scene in order to improve outcome, particularly those with traumatic brain injury (TBI) (Bernard et al, 2010).
Furthermore, it was refreshing to see a more nuanced analysis of the oft-quoted San Diego RSI study, which would arguably not constitute an acceptable level of clinical governance in any high performance clinical system. Indeed, recent evidence suggests that it is not base speciality or profession, but rather a clearly defined system of training and education embedded within robust governance frameworks, combined with high levels of exposure enabling skills maintenance, that improves both competence and outcome (McQueen et al, 2015).
As this paper is aimed at UK-based trauma systems, the omission of Jashapara's CCP evaluation paper (Jashapara, 2011) from the discussion seems a little odd; while a paper comparing a Franco-German model to a US-based system is also likely to attract attention (Schmidt et al, 1992). Nonetheless, it is refreshing to see a more balanced, less adversarial and critical appraisal of some of the issues in pre-hospital trauma care.
Spotlight on Research is edited by Julia Williams, principal lecturer, paramedic science, University of Hertfordshire, Hatfield, Hertfordshire, UK. To find out how you can contribute to future issues, please email her at j.williams@herts.ac.uk