title: Advanced training in trauma life support for ambulance crews.
abstract: BACKGROUND
  There is an increasing global burden of injury especially in low- and middle-income countries (LMICs). To address this, models of trauma care initially developed in high income countries are being adopted in LMIC settings. In particular, ambulance crews with advanced life support (ALS) training are being promoted in LMICs as a strategy for improving outcomes for victims of trauma. However, there is controversy as to the effectiveness of this health service intervention and the evidence has yet to be rigorously appraised.
  
  
  OBJECTIVE
  To quantify the impact of ALS-trained ambulance crews versus crews without ALS training on reducing mortality and morbidity in trauma patients.
  
  
  METHODS
  The search for studies was run on the 16th May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), PubMed and screened reference lists.
  
  
  METHODS
  Randomised controlled trials, controlled trials and non-randomised studies, including before-and-after studies and interrupted time series studies, comparing the impact of ALS-trained ambulance crews versus crews without ALS training on the reduction of mortality and morbidity in trauma patients.
  
  
  METHODS
  Two review authors assessed study reports against the inclusion criteria, and extracted data.
  
  
  RESULTS
  We found one controlled before-and-after trial, one uncontrolled before-and-after study, and one randomised controlled trial that met the inclusion criteria. None demonstrated evidence to support ALS training for pre-hospital personnel. In the uncontrolled before-and-after study, 'a priori' sub-group analysis showed an increase in mortality among patients who had a Glasgow Coma Scale score of less than nine and received care from ALS trained ambulance crews. Additionally, when the pre-hospital trauma score was taken into account in logistic regression analysis, mortality in the patients receiving care from ALS trained crews increased significantly.
  
  
  CONCLUSIONS
  At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews on patient outcomes.
authors.affiliation: Division of Trauma, Critical Care and Emergency Surgery, Virginia Commonwealth University, West Hospital 15th Flr East Wing, 1200 East Broad Street, Richmond, VA, USA, 23219.
authors.forename: Sudha
authors.initials: S
authors.lastname: Jayaraman
authors.forename: Dinesh
authors.initials: D
authors.lastname: Sethi
authors.forename: Roger
authors.initials: R
authors.lastname: Wong
mesh_terms: D061906:Advanced Trauma Life Support Care; D000552:Ambulances; D018849:Controlled Clinical Trials as Topic; D004634:Emergency Medical Technicians / Q000193:education*; D015600:Glasgow Coma Scale; D006801:Humans; D008020:Life Support Care; D016032:Randomized Controlled Trials as Topic; D014194:Traumatology / Q000193:education*; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy