The Advanced Trauma Life Support Course (ATLS®) was created in order to educate emergency physicians and improve trauma care within a secondary care setting. Following its success, the need for an equivalent course focusing on the pre-hospital phase of trauma care was identified and the Pre-Hospital Trauma Life Support (PHTLS®) course was proposed (1–3). The PHTLS® course aims to improve the quality of care that (poly)trauma patients receive in the earlier phases of the chain of trauma (2, 4) and consists of a two-day interactive program accompanied by a structured course manual (5). In less developed medical systems, PHTLS® courses have been demonstrated to have a beneficial effect both in terms of participant skills and patient outcome (6–8). However, the benefit of PHTLS® courses in developed high-level medical systems remains relatively unexplored. It has been assumed that even within this context there is a significant improvement in patient outcomes following PHTLS® training.

Demographic studies suggest that accident-related trauma cases are becoming rarer in Western-Europe which decreases the exposure and experience of qualified medical personnel to such cases (9). Structured training concepts such as PHTLS®, which entails theoretical background and intensive team scenario trainings, may compensate for this issue (10). In line with other European countries, various healthcare professionals in Switzerland collaborate to facilitate pre-hospital trauma care (e.g., paramedics, fire fighters and medical doctors) (11–13). The PHTLS® course is open to all first responders as it accommodates for various professions and skillsets, nevertheless it is unclear if a specific group of healthcare providers receives a greater benefit than others. The values gained by well-trained personnel from the training program is still a topic of debate. The aim of the current study was to determine the impact of PHTLS(r) course participation among a heterogeneous group of healthcare professionals on self-confidence, communication, and methodology during the treatment of severe trauma. Additionally, the role of medical profession, work experience, and prior course participation on reported outcome was analyzed.

A total of 115 potential participants were contacted, of whom 8 qualified as transport paramedics (TP), 82 were emergency paramedics (EP) and 25 worked as emergency medical doctors (EMD). A total of 87 healthcare professionals who completed interviews were eligible for analysis leading to an overall response rate off 76%. Further breakdown shows 66/82 emergency paramedics, 15/25 emergency medical doctors, 6/8 transport paramedics participated.

31 participants were involved in the PHTLS® course prior to 2008, whereas 47 individuals completed the course between 2008 and 2015. Nine of the participants did not declare when they participated in the course. Overall years of experience in the field of pre-hospital emergency care prior to course participation was 6.7 ± 5.2 years. The TP-group had an average of 5.8 ± 1.7 years of experience, whereas the EP-group had 7.1 ± 5.7 years, and the EMD-group had 4.5 ± 2.0 years. Emergency paramedics have significantly more working experience than emergency physicians (p = 0.004). The following additional courses have been completed by the participants prior to PHTLS® training: Advance Medical Life Support (AMLS®) (n = 48), Megacode (n = 20), Advanced Trauma Life Support (ATLS®) (n = 17) and Advanced Cardiac Life Support (ACLS®) (n = 5). Other courses completed included: European Pediatric Advanced Life Support (EPALS) and the Pediatric Advanced Life Support (PALS). Characteristics of participants of different study groups are shown in Table 1, no comparison of specific course participation between groups was performed.

This study revealed that successful PHTLS® course completion is associated with improved self-confidence when treating severe trauma patients in the pre-hospital setting among medical emergency personnel in a European metropolitan area. The profession of emergency paramedic, rather than working experience or alternative course participation, was predictive for increased self-confidence. In addition, PHTLS® training resulted in improved communication among healthcare personnel as well as altered pre-hospital care pathways.

The results imply that healthcare professionals in well-developed regions, regardless of background, may benefit from PHTLS® training as both self-confidence and quality of communication noticeably improved after course participation. This is independent of extensive working experience and prior completion of other trauma courses. Based on the multivariable analysis performed the profession that benefits most from the completion of the course is emergency paramedics.

The findings of the current study show that PHTLS® course completion can be linked to the improvement of self-confidence when managing pre-hospital trauma patients and the overall quality of communication. Studies have shown PHTLS® courses provide various additional benefits. Johansson et al. demonstrated that PHTLS® training of Swedish ambulance personnel is associated with reduced mortality (11). Similar improvements in mortality have been described in less developed countries (6–8). A study from Haeske et al., reported quality of documentation was improved upon PHTLS® course participation (5). The current study along with the information reported by Haeske et al. both demonstrate a real impact of the PHTLS course leading to healthcare professionals altering real patient care upon course completion (5). This is further supported by a study from Ali et al. who reported that pre-hospital trauma care was altered, specifically by more frequent airway control, oxygen suppletion, C-spine control, hemorrhage management and fracture splinting (15).

Based on a previous studies, it is tempting to hypothesize that there are superior outcomes relating to improved efficacy of care in trauma pre-hospital care upon the completion of PHTLS® training (5). Increased efficiency due to PHTLS® training may partly be explained by increased clinical and management skills (Ali et al.) (16). Increased self-confidence and better communication, as found in the current study, most likely also contribute to the overall improvement in pre-hospital care.

It has been previously demonstrated, that in addition to real-life experience, training programs/courses have the potential to boost self-confidence in performing life-saving interventions in trauma (17). Although, in line with Haeske et al., it was found that the quantitative amount of real-life working experience did not affect the impact course participation had on altered self-confidence in pre-hospital trauma care (18). The findings of the current study further suggest that prior participation in other official (trauma) courses does not influence reported changes in subjective improvement upon PHTLS® course completion. Even though, certain factors are not influenced by course participation, this investigation implies that the PHTLS® course is advantageous for all health care professionals. Hence this training should be considered as complementary to alternative (trauma) courses (19, 20). Of note, as there is overlap between the PHTLS®-training and other courses, the specific impact of PHTLS® itself cannot be extracted by the current study as no other intervention group has been included in this study (21). Theoretically, post-course improvement can be expected with other courses than PHTLS® as well.

The current study has several limitations. Firstly, it is a subjective self-reported evaluation of the impact of PHTLS® course participation, rather than a test of pre-hospital care competence. Nevertheless, self-assessments are an adequate tool to determine alterations in quality of care (22). Secondly, the benefit of course participation in (para)medical students was not studied, as only medical professionals with relevant working experience have been contacted. Future studies should focus on the potential role of the PHTLS® course in the education/curriculum of (para)medical students. Besides, no detailed information on timing and exact content of prior course participation was collected. Furthermore, the time interval between course participation and survey participation differs between participants. Future follow-up studies are indicated to analyze the development of self-confidence and communication skills among medical emergency personnel over time, as well as the need for PHTLS®-refresher courses.

The current study reveals that PHTLS® training is associated with improved self-confidence and enhanced communication among medical emergency personnel in a European metropolitan area when treating severe trauma patients in the pre-hospital setting. The profession of medical paramedic, rather than working experience or alternative course participation, was predictive for increased self-confidence after PHTLS® course participation. In conclusion, it can be stated that medical personal involved in the pre-hospital care of trauma patients, in a metropolitan area in Europe, can benefit from PHTLS® training. This is independent of the persons function (transport/emergency paramedic or medical physician), previous working experience or prior alternative course participations.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Zurich University Hospital medical ethics committee (protocol no.: KEK-ZH: 2011-0493). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements.

MT: Writing – original draft, Writing – review & editing. NL: Writing – original draft, Writing – review & editing. AS: Writing – original draft, Writing – review & editing. TB: Writing – review & editing. KJ: Writing – original draft, Writing – review & editing. EM: Writing – review & editing. MB: Writing – original draft, Writing – review & editing. SM: Writing – original draft, Writing – review & editing. RP: Writing – original draft, Writing – review & editing. LM: Writing – review & editing. HP: Writing – review & editing. KS: Writing – review & editing.