Background

Germany has a long history of committed cooperation between trauma surgeons and anesthetists emphasizing the importance of a coordinated “chain of rescue” for the outcome of trauma victims. Milestones of this commitment were the introduction of prehospital trauma care, including helicopters, systematic primary evaluation in the emergency room, early operative stabilization as needed, and the initiation of rehabilitation in specialized centers. In 1983, Trunkey suggested that the German Trauma System was a blueprint for further improvements in America when he said that “Germany has by far the best trauma system in the world” during the meeting of the German Trauma Society.

When the Committee on Trauma of the German Trauma Society discussed educational programs to systematically educate young trauma surgeons, anesthetists, and other specialists who were involved in the primary management of trauma patients, the group discussed whether Advanced Trauma Life Support (ATLS) was an option for a systematic evaluation of the trauma patient when entering the hospital.

ATLS is an internationally established, standardized concept for the early management of critically injured patients. The concept should help physicians to set priorities, minimize mistakes, and put theoretical knowledge into action [1–4]. Davis et al. [5] showed that 53 % of significant medical errors which led to repercussions on the treatment outcome occurred in the shock room phase of the trauma treatment. This fact leads the way to a structured training program for the shock room phase—a program that emphasizes the diagnosis of life-threatening injuries and focuses on the stabilization of vital signs.

The ATLS concept presented a solution—a clear set of guidelines and guidance—although not the only one—for the care of serious trauma patients [6–8]. The program developed in 1978 is based on the ABCDE scheme. A stands for Airway, B for Breathing, C for Circulation, D for Disability, and E for the Environment. The process of the scheme is priority oriented, which means that the most life-threatening situation will be treated first.

In the midst of indecisiveness, chaos, and hecticness, a delay in the decision-making process increases the post-traumatic morbidity and mortality [7, 9]. In a study about the effectiveness of treatment guideline utilization in the shock room, Ruchholtz et al. reported that the time needed to carry out diagnostic procedures and the time needed to begin with essential therapeutic measures could be shortened with the implementation of treatment guidelines immediately [10–12].

The American College of Surgeons Committee on Trauma (ACSCOT) described several factors that influenced the efficiency during the emergency room phase. These include error in technique, error in judgment, error in diagnosis, and system inadequacy. These factors relate to the morbidity and mortality rates in the trauma bay [13, 14].

In the USA as well as in many European countries and other parts of the world, the ATLS concept has become a mandatory part of ongoing medical education, and a definitive requirement for any work in the trauma bay [15–17]. In 2003, the German Society of Trauma Surgery (DGU, Deutsche Gesellschaft für Unfallchirurgie) introduced the first ATLS course in Germany.

Before introducing ATLS in Germany, there were controversial discussions about its potential benefits. The main argument was that the ATLS program was not necessary since Germany already had a well-developed and internationally recognized trauma system.

The aim of this study was to evaluate the acceptance and the general perception towards the requirement of such a course.

Method

In total, 2,968 participants have become certified ATLS providers in Germany between March 2003 and December 2010.

Participants are being trained in six different national course centers all over Germany. In-house courses are also available.

Up to 16 participants in each course are guided through the 2-day training by up to eight instructors. The instructors’ and participants’ professions are from all fields concerned with severely injured patients.

Each of the attended courses was evaluated by the participants and the comprehensive evaluation of each course was further investigated (n = 197). Each individual presentation, practical skill station, surgical skill station, and, with that, the performance of every participating instructor were marked. The entire course, along with the ATLS concept, is graded on a scale of 1–4 as well, with grade 1 representing very good and 4 poor, while grade 2 represents good and 3 satisfactory. The course coordinator made sure that all evaluation forms from all the students were returned anonymously at the end of the course.

The feedback was entered in a database and statistically analyzed (Excel® Microsoft for Windows, USA, 2010).

Metric data were compared using the Student’s t-test. Descriptive results are demonstrated as the mean (range). The level of significance was defined as p = 0.05.

The study is approved by the Ethics Committee of Rhineland-Palatine under number 837.032.11 (7574).

The participants were composed of 65 % surgeons (n = 1,929), 29 % anesthesiologists (n = 861), and 6 % other specialists who were not generally considered to be directly involved in trauma care. General practitioners and internists made up 3 % (n = 89), while radiologists, neurologists, and pediatricians were also integrated into the courses.

Results

The overall course evaluation averages received the highest score: 1.39 (1.06–1.86; n = 197). Concerning individual evaluations, the average of all presentations was 1.61 (1.00–2.81; n = 197). The practical skill stations had an excellent evaluation grade of 1.40 (1.00–2.40; n = 197) (Fig. 1).

Fig. 1
figure 1

Providers’ evaluation of the different sections of the ATLS program (grade 1 very good, grade 4 poor)

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Therefore, the non-surgical skill stations received an excellent grade, as did the chest X-rays interpretation stations 1.24 (1.00–1.73; n = 197) and spinal films 1.28 (1.00–1.94; n = 197). The other stations were also well marked: airway and ventilatory management 1.47 (1.00–2.31; n = 197), shock assessment and management 1.52 (1.00–2.37; n = 197), head and neck trauma 1.39 (1.06–2.00; n = 197), spinal cord injury assessment and management 1.47 (1.1–2.07; n = 197), and musculoskeletal trauma assessment and management 1.52 (1.06–2.06; n = 197) (Fig. 2).

Fig. 2
figure 2

Evaluation of the surgical skill stations (grade 1 very good, grade 4 poor)

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All surgical skill stations were rated overall at 1.36 (1.00–2.38; n = 197) (Fig. 2). Each station was rated as follows: cricothyroidotomy 1.31 (1.00–2.00; n = 197), chest decompression 1.33 (1.00–2.00; n = 197), pericardiocentesis 1.38 (1.00–2.38; n = 197), and diagnostic peritoneal lavage 1.41 (1.00–1.94; n = 197) (Fig. 3).

Fig. 3
figure 3

Evaluation of the practical skill stations (grade 1 very good, grade 4 poor)

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Participant comments and evaluations confirm the highest grade of 1.24 (1.00–1.57; n = 197) for practical skills simulation (case scenarios).

Analysis of the results of each year shows that there is no significant change in the evaluations of the entire course or each part over time (Fig. 4).

Looking at the number of courses and the participants, there was an increasing growth over the years (Figs. 4 and 5). In 2005, there were only a few courses, but over the years, this number became larger and larger. In 2009, there were 47 courses and in 2010, there were 67 in total.

Fig. 4
figure 4

Evaluation distributed over the years (range) (grade 1 very good, grade 4 poor)

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Fig. 5
figure 5

Number of ATLS courses over the years in Germany

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Discussion

The individual evaluations of 197 ATLS courses in Germany support the success of the ATLS concept. The evaluations’ results show that the ATLS courses cover successful training concepts. An evaluation of the presentations with an average of 1.61 can be traced back to the thoroughly didactic preparation of the instructors. The evaluation of the hands-on skills (surgical skills 1.36, practical skills 1.41) demonstrates the optimal construction of the course in its entirety. The simulation was given the highest rating by the participants, showing that the course resembles realistic trauma situations.

The two X-ray skill stations were rated high as well. The reason for this is probably the rarely practiced interpretation of chest or spine X-ray of anesthetists and surgeons in everyday life. However, also, radiologists rated this station very high, as they learn about a structured assessment of X-ray film in the course, which is a great success in our opinion.

The overall course evaluation averages received a very good score of 1.39 (1.06–1.86). This indicates not only the high acceptance, but, together with the growing numbers of courses, it further suggests a necessity of such a trauma care format.

As there is no significant change of the results over the years, this course format should still be valuable for the residency education in the field of trauma and the slight changes and improvements of the format over time were well placed.

According to our findings, all these results support the value of the ATLS format. The high acceptance of this standardized trauma training suggests that ATLS does fit in a country with a good working trauma and emergency care system like Germany.

Although our study showed very good evaluations and although “hands-on” elements are already playing an important role in our course system, the participants always call for a higher percentage of these elements.

Already, Ali et al. [18] were able to demonstrate the important role. After adding “hands-on” elements with simulated trauma patient models to the TEAM program (Trauma Evaluation and Management), both the post-test scores and the evaluation of the skill improvement improved significantly. This TEAM program is an introduction within the ATLS concepts to teach medical students.

Interactive lectures and discussions play a vital role in adult learning. However, clinical skills require more interaction between students and the instructor. Mechanical models, surgical skills laboratory, and standardized live subjects broaden the experience of the participants and lead to a better learning result [19–23].

The study of Kennedy and Gentleman surveyed 228 ATLS providers in Scotland. A questionnaire was sent to all participants of all 21 ATLS courses in this area between 1991 and 1994. Compared to ours, these results showed the highest scoring for the moulage skill station. It also showed that 97 % noted improvement of their clinical skills after the course. At least 25 % stated that it was a substantial improvement [24].

These perceived improvements occurred in all grades and specialties across the board, reflected in the finding that 98 % of those surveyed would encourage younger doctors and 88 % would encourage more advanced doctors to attend the course [24].

79 % of the questioned surgeons and 69 % of the anesthetists thought an ATLS provider status should be compulsory for specialist examinations [24].

However, the question remains as to whether ATLS improves the outcome of severely injured trauma patients. A Cochrane review from 2009 showed that the evidence for the impact of the ATLS program on trauma outcome is poor. The difficulty of interpretation is a complex process in the entire hospital and, therefore, different factors influence the patients’ outcome [25].

Jayaraman and Sethi remarked that the format has more an educational approach than a process approach. There is some evidence that the educational initiatives improve knowledge of the treatment of trauma patients [25, 26].

In Germany, ATLS also provides the required standards in the hospitals, which participate in one of the trauma networks being initiated right now; therefore, ATLS is a major patient safety tool. In the Netherlands, for example, ATLS is also a safety tool concerning issues such as treatment and incidents [27].

As already mentioned, participants, instructors, and directors endorse the course’s multidisciplinary make up. This assures equal importance to anesthesiologists and surgeons, while other specialists are likewise integrated.

The shared language and communication of ATLS shows a significant advantage over other training programs. The shared algorithm allows the Prehospital Trauma Life Support (PHTLS) program, a prehospital version of ATLS designed for emergency medical technicians, to optimize patient care. Through this concept, time can be saved at the accident scene, a structured ABCDE patient report can be made, and essential information can be communicated faster and more clearly [28, 29].

To ensure the high quality of the ATLS courses in Germany in the future, we founded the ATLS research group. The aim of the group is to improve the quality of the provider courses. Furthermore, we are investigating to improve the sustainability of the knowledge and the skills taught in the course. The evaluation and development of the instructor courses is another step to improve not only the instructors but most of all the ATLS format.

With over 197 courses and almost 3,000 providers by the end of 2010, ATLS has not only become a pillar in the modern care of severely injured patients, but it is also an important factor concerning the standardized education of trauma care in Germany.

Conclusion

In contrast to transferring theoretical knowledge and practical skills, the educational and problem-oriented presentation is a likely explanation for the success of Advanced Trauma Life Support (ATLS).

The concept is interdisciplinary, no matter which medical specialists are involved in the care of the severely injured—they all speak the same language: ATLS.

The continuous feedback on one hand helps the instructors to improve their teaching skills; on the other hand, however, it helps to improve the entire ATLS concept, so that it can be adopted in a constructive way.

The growing number of courses and the evaluation scores support the format as well as the teaching of the standardized care of severely injured patients in an industrialized country like Germany.

Further studies with analysis by means of the German Trauma Registry data are planned in order to verify whether ATLS improves the outcome of trauma patients. Finally, the most important goal for ATLS is to improve the participants’ knowledge and skills and, thus, to improve the patient safety in the trauma bay.