The association of advanced life support training and decreased per capita trauma death rates: an analysis of 12,417 trauma deaths

This study identified a number of significant predictors of per capita county trauma mortality rates: rurality, percentage nonwhite population, percentage unemployment, and Advanced Life Support (ALS) versus Basic Life Support (BLS) status. Of these, ALS versus BLS status is not only the most significant independent predictor, it is the only predictor readily amenable to change. The aspects of ALS clearly associated with decreased trauma death rates should be identified and, if possible, undergo widespread implementation.

Advanced life support vs basic life support field care: an outcome study

OBJECTIVE

To determine whether the provision of advanced life support (ALS) field care has any impact on patient outcome in the urban Canadian environment.

METHODS

A convenience cohort study was conducted of all emergent ambulance transfers of adults to an urban Canadian hospital from May 22 to July 31, 1996. Data were collected from ambulance call reports regarding presenting complaint and field interventions applied, and from hospital records regarding time in the ED, hospital length of stay (LOS), and discharge disposition. Patient outcomes were compared within 7 presenting complaint groups (chest pain, altered level of consciousness, shortness of breath, abdominal pain, motor vehicle crash, falls, and other) by field care level: level 1--BLS (basic life support) vs levels 2 and 3--ALS.

RESULTS

The study population consisted of 1,397 patients. No significant differences were seen between BLS and ALS patients on baseline demographics. ED triage score did not depend on field care level for any group, implying that those in the ALS group were not inherently sicker. Outcome measures (ED LOS, admission rates, and hospital LOS) showed no significant differences between BLS and ALS for each presenting complaint group. Discharge dispositions were analyzed by chi2 but were not varied enough to allow reliable analysis. Observation of trends suggested no difference between BLS and ALS.

CONCLUSIONS

There was no beneficial impact on the measured patient outcomes found in association with the provision of ALS vs BLS field care in Metropolitan Toronto for patients who were brought to a nontrauma center.

[Limiting life sustaining therapies]

INTRODUCTION

Intensivists are increasingly implementing end-of-life decisions in patients who remain dependent on life sustaining therapies without hope for recovery.

STATE OF THE ART

Descriptive studies have provided epidemiological data on ICU end-of-life care, identifying areas for improvement. Qualitative studies have highlighted the complexity of the decision making process. In addition to considering the legal and ethical issues involved, this review describes cultural, religious and individual variations observed in ICU end-of-life care. It is important for intensivists to respect patients' preferences and values, but also, in some family members, to avoid increasing the burden and the guilt of sharing the decision.

CONCLUSION

Intensivists should improve their ability to meet the needs of dying patients and their family members. Each situation, patient, family and caregiver is unique, and therefore needs a specific approach. Introducing palliative care and multidisciplinary teams into the ICU might provide an additional opportunity for patients and families to be informed and listened to.