Campbell, NicolaLilley, RebbeccaDavie, GabrielleMorgaine, KateDicker, BridgetKool, Bridget2026-06-082026-06-082025-10-11Australasian Emergency Care, ISSN: 2589-1375 (Print); 2588-994X (Online), Elsevier, 29(2), 138-145. doi: 10.1016/j.auec.2025.09.0082589-13752588-994Xhttp://hdl.handle.net/10292/21344OBJECTIVE: To examine the relationship between prehospital Advanced Life Support (ALS) and survival to hospital for major trauma patients in New Zealand and explore its implications for Emergency Medical Service (EMS) practice. METHODS: A mixed-methods explanatory design was used. Data on major trauma patients attended by road EMS (December 2016-November 2018) was analysed. A multivariable model with propensity scores estimated the odds of survival for patients receiving Advanced versus Basic Life Support (BLS). Semi-structured interviews conducted with EMS stakeholders were analysed using thematic analysis. RESULTS: Among 1118 patients, 661 (59 %) received ALS. Only 52 (5 %) did not survive to hospital. Multivariable modeling estimated ALS recipients had 1.5 times higher odds of survival than BLS-only recipients (OR 1.49, 95 % CI 0.66-3.35). Interviews with five EMS clinical leaders highlighted two likely influences: clinical judgment and evidence use. Despite imprecise quantitative findings, stakeholders supported ALS based on clinical judgment. CONCLUSIONS: A tension between population-level results and provision of care based on clinical judgement exists. Quantitative analysis found no evidence that ALS offers a survival benefit, although considerable uncertainty exists, whereas stakeholders perceive ALS has clinical and equity benefits. Future research should assess equity, disability, and quality of life outcomes of ALS.© 2025 The Authors. Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).http://creativecommons.org/licenses/by/4.0/Emergency careEmergency medical servicesEmergency paramedicineEvidence based practiceLife support careNew ZealandPrehospital4203 Health Services and Systems32 Biomedical and Clinical Sciences3202 Clinical Sciences42 Health SciencesEmergency CareClinical Research1110 Nursing1117 Public Health and Health ServicesNursing3202 Clinical sciences4203 Health services and systems4205 NursingHumansNew ZealandMaleFemaleMiddle AgedAdultEmergency Medical ServicesCohort StudiesWounds and InjuriesAgedLife Support CareQualitative ResearchPropensity ScoreHumansWounds and InjuriesLife Support CareCohort StudiesQualitative ResearchAdultAgedMiddle AgedEmergency Medical ServicesNew ZealandFemaleMalePropensity ScoreHumansNew ZealandMaleFemaleMiddle AgedAdultEmergency Medical ServicesCohort StudiesWounds and InjuriesAgedLife Support CareQualitative ResearchPropensity ScoreJournal ArticleOpenAccess10.1016/j.auec.2025.09.008