Effect of Physician-Staffed Emergency Medical Services (P-EMS) on the Outcome of Patients with Severe Traumatic Brain Injury: A Review of the Literature

Figures & data

Table 1. Study characteristics

Authors	Study Design	Country	Time frame	Population size	Included age	Key findings
Baxt (1987)^Citation12	Cohort	USA	50-month period	232	ND	9% reduction in mortality (p < 0.001) and reduction in GOS (p < 0.05) after physician-staffed aeromedical service.
Di Bartolomeo (2001)^Citation17	Cohort	Italy	1998–1999	184	All ages	Significant difference only found in patients with GCS 10–12, in favor of EMS: mortality P-EMS 24% vs. EMS 0%.
Garner (2001)^Citation19	Cohort	Australia	1986–1998	296	ND	CCT associated with better outcome in GOS (p = 0.0013).
Klemen (2006)^Citation15	Cohort	Slovenia	1998–2004	64	18–82	Improvement in GOS (p = 0.01) and shortened hospitalization time (p < 0.04) after physician assistance. Reduction in hospital mortality only for GCS 6-8 (p < 0.01).
Aydin (2010)^Citation23	Cohort	The Netherlands	2005–2007	98	0–91	No significant differences in mortality between P-EMS and EMS.
Engel (2010)^Citation16	Cohort	Australia versus Germany	2002–2007	10183	27–73	Increased mortality, hypotension, hospitalization time and number of craniotomies after physician assistance (p < 0.001).
Bulger (2012)^Citation18	Cohort	USA	2006–2009	1238	> 14	Higher proportion of patients with poor neurologic outcome after P-EMS (p < 0.001).
De Jongh (2012)^Citation24	Cohort	The Netherlands	2003–2008	158	ND	No significant difference in mortality.
Taylor (2012)^Citation25	Cohort	Australia	2000–2010	1067	> 16	P-EMS considered as more effective in reducing mortality, but no significance defined.
Franschman (2012)^Citation20	Cohort	The Netherlands	2003–2007	497	> 9	Improved GOS after physician assistance (p = 0.03). Increased incidence of hypotension after physician assistance (p = 0.04).
Franschman (2013)^Citation22	Cohort	The Netherlands	2008–2009	399	> 15	No significant difference in mortality, but EMS patients are more often secondary referred to specialized neurotrauma centers.
Garner (2015)^Citation13	RCT	Australia	2005–2011	598	> 15	Significant reduction in mortality and proportion of hypotensive patients after physician assistance for patients with GCS < 9 only (original definition of severe head injury).
Pakkanen (2016)^Citation14	Cohort	Finland	2005–2010	458	0–90	Reduced mortality and less hypotensive patients after physician assistance (p ≤ 0.001).
Pakkanen (2017)^Citation21	Cohort	Finland	2005–2010 2012–2015	266	ND	Improved GOS and decreased incidence of hypoxia after physician assistance (p < 0.03).

CCT = critical care team (including physician); ND = not defined.

Table 2. Outcome measures

Authors	Mortality	Neurological outcome	Hypotension	Hypoxia	Length of Stay	Neurosurgical interventions
Baxt (1987)^Citation12	Land group: 40% Aeromedical group: 31% P < 0.001	GOS 0 (Good) Land: 16% Aeromedical: 31% P < 0.05	X	X	X	No statistical difference
Di Bartolomeo (2001)^Citation17	EMS: 24% P-EMS: 30% OR 1.39 95% CI 0.72–2.67 If GCS 10–12: EMS: 0% P-EMS: 24% OR 1.54 95% CI 1.12–2.12	Mean GOS EMS: 3,9 P-EMS: 4,2 Not significant	SBP < 90 mmHg EMS: 22% P-EMS: 23% Significance NA	X	X	EMS: 28% P-EMS: 15% Significance NA
Garner (2001)^Citation19	GOS = 5 (death) Paramedic: 32% CCT: 20% Significance NA	CCT associated with improved GOS Univariate: OR 2.22 95% CI: 1.25–3.94 (p = 0.0063) Multivariate: OR 2.70 95% CI: 1.48–4.95 (p = 0.0013)	SBP < 90 mmHg EMS: 14% P-EMS: 24% P = 0.10	X	X	X
Klemen (2006)^Citation15	EMT: 42% EP: 40% P = 0.076 If GCS 6-8: EMT: 76% EP: 22% P < 0.01	Good (GOS 4–5) EMT: 33% EP: 53% P = 0.01 Poor (GOS 2-3) EMT: 25% EP: 7% P = 0.01	SBP hospital admission EMT: 105 +/- 35 mmHg EP: 132 +/- 32 mmHg P = 0.03	SaO2 hospital admission EMT: 89% +/- 8% EP: 96% +/- 3% P = 0.04	ICU (days) EMT: 19.7 EP: 11.2 P = 0.01 Trauma (days) EMT: 44.8 EP: 33.1 P = 0.04	X
Aydin (2010)^Citation23	30-day mortality Non-MMT: 32.7 MMT: 25.6% P = 0.442	X	X	X	X	X
Engel (2010)^Citation16	EMS: 9,9% P-EMS: 21,2% P < 0.001	X	SBP < 90 mmHg at ED EMS: 3,7% P-EMS: 6,2% P < 0.0001	X	ICU (> 14 days) EMS: 3.1% P-EMS: 24.1% P < 0.0001) Hospital (>14 days) EMS: 15,3% P-EMS: 48,9% P < 0.0001	Craniotomy EMS: 11,4% P-EMS: 18,3% P < 0.0001
Bulger (2012)^Citation18	EMS: 23,4% P-EMS: 27,7% P = 0.091	GOSE ≤ 4 (Poor) EMS: 48.3% P-EMS: 59.0% P < 0.001	Mean SBP at arrival EMS: 141.0 mmHg P-EMS: 135.4 mmHg P = 0.003	X	X	X
De Jongh (2012)^Citation24	EMS: 44% P-EMS: 61% Significance NA Adjusted OR 1.3 95% CI: 0.6–2.7	X	X	X	X	X
Taylor (2012)^Citation25	EMS: 19.9% P-EMS: 17.9% Significance NA	X	X	X	X	X
Franschman (2012)^Citation20	Mortality rate EMS: 0,44 P-EMS: 0,38 Not significant	Median GOS EMS: 2 (1–5) P-EMS: 4 (1–6) P = 0.03	X	O2 saturation < 92% EMS: 40% P-EMS: 39% Not significant	X	X
Franschman (2013)^Citation22	EMS: 44% P-EMS: 47% P = 0.77	X	SBP ED arrival EMS: 139 mmHg P-EMS: 129 mmHg P = 0.03	SpO2ED arrival EMS: 97% P-EMS: 97% P = 0.84	X	X
Garner (2015)^Citation13	GCS < 9 30-day mortality EMS: 45% P-EMS: 29% P = 0.005 GCS 3–12, AIS≥ 3 30-day mortality EMS: 36% P-EMS: 29% P = 0.13	GCS < 9 Poor GOS EMS: 53% P-EMS: 50% P = 0.59 GCS 3–12, AIS≥ 3 Poor GOS EMS: 58% P-EMS: 56% P = 0.76	GCS < 9 EMS: 7% P-EMS: 7% P = 0.79 GCS 3–12, AIS≥ 3 EMS: 11% P-EMS: 11% P = 0.98	GCS < 9 EMS: 14% P-EMS: 4% P < 0.001 GCS 3–12, AIS≥ 3 EMS: 10% P-EMS: 5% P = 0.05	GCS < 9 ICU (days) EMS: 7 P-EMS: 7 Hospital (days) EMS: 5 P-EMS: 6 P > 0.05 GCS 3–12, AIS≥ 3 ICU (days) EMS: 10 P-EMS: 7 Hospital (days) EMS: 18 P-EMS: 11 P > 0.05	X
Pakkanen (2016)^Citation14	One-year mortality EMS: 57% P-EMS: 42% OR 1.86 95% CI 1.27–2.71 P = 0.001	Good (GOS 4–5) EMS: 32% P-EMS 38% P = 0.14	EMS: 4% P-EMS 4% Significance not defined	EMS: 10% P-HEMS: 1% OR 10.05 95% CI 2.91–34.67 P < 0.001	X	X
Pakkanen (2017)^Citation21	X	Good (GOS 4–5) EMS: 28% P-EMS: 42% P = 0.022	EMS: 4% P-EMS: 5% P = 0.750	EMS: 10% P-EMS: 2% P = 0.024	X	X

CCT = critical care team (including physician); EMT = emergency medical technician; EP = emergency physician; MMT = mobile medical team; GOSE = extended Glasgow Outcome Scale; NA = not available.

Figure 1. Flowchart of the search and selection process.

Figure 2. Outcome measures.

Table 3. Quality assessment

Authors	Study design	Level of Evidence	Newcastle-Ottawa Scale											Cochrane Collaboration’s tool for assessing risk of bias
			Selection				Comparability		Outcome
			S1	S2	S3	S4	C1	C2	O1	O2	O3	Total Score (out of 9)		A	B	C	D	E	F	G
Baxt (1987)^Citation12	Cohort	Level 3	*	*	*	*			*	*	*	*******	(7)
Di Bartolomeo (2001)^Citation17	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
Garner (2001)^Citation19	Cohort	Level 3	*	*	*	*	*	*	*	*		********	(8)
Klemen (2006)^Citation15	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
Aydin (2010)^Citation23	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
Engel (2010)^Citation16	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
Bulger (2012)^Citation18	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
De Jongh (2012)^Citation24	Cohort	Level 3	*	*	*	*	*	*	*		*	********	(8)
Taylor (2012)^Citation25	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
Franschman (2012)^Citation20	Cohort	Level 3	*	*	*	*	*	*	*	*	–	********	(8)
Franschman (2013)^Citation22	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
Garner (2015)^Citation13	RCT	Level 2												Low	Low	NA	Low	Low	Low	Low
Pakkanen (2016)^Citation14	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)
Pakkanen (2017)^Citation21	Cohort	Level 3	*	*	*	*	*	*	*	*	*	*********	(9)

The aspects that met the requirements of the quality assessment are represented with an asterisk.

NA = not available.

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