Annals of Emergency Medicine
Volume 55, Issue 3 , Pages 235-246.e4 , March 2010

Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort

Presented as an abstract at the Society for Academic Emergency Medicine Annual Meeting, May 2008, Washington, DC.

  • Craig D. Newgard, MD, MPH

      Affiliations

    • Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
    • Corresponding Author InformationAddress for correspondence: Craig D. Newgard, MD, MPH, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code CR-114, Portland, OR 97239-3098; 503-494-1668, fax 503-494-4640
    • ,
  • Robert H. Schmicker, MS

      Affiliations

    • Department of Biostatistics, University of Washington, Seattle, WA
    • ,
  • Jerris R. Hedges, MD, MS, MMM

      Affiliations

    • Department of Medicine, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, HI
    • ,
  • John P. Trickett, BScN

      Affiliations

    • Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
    • ,
  • Daniel P. Davis, MD

      Affiliations

    • Department of Emergency Medicine, University of California at San Diego, San Diego, CA
    • ,
  • Eileen M. Bulger, MD

      Affiliations

    • Department of Surgery, University of Washington, Seattle, WA
    • ,
  • Tom P. Aufderheide, MD

      Affiliations

    • Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
    • ,
  • Joseph P. Minei, MD

      Affiliations

    • Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
    • ,
  • J. Steven Hata, MD, FCCP, MSc

      Affiliations

    • Department of Anesthesia, Division of Critical Care, University of Iowa, Iowa City, IA
    • ,
  • K. Dean Gubler, DO, MPH

      Affiliations

    • Legacy Emanuel Trauma Program, Portland, OR
    • ,
  • Todd B. Brown, MD, MSPH

      Affiliations

    • Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL
    • ,
  • Jean-Denis Yelle, MD

      Affiliations

    • Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
    • ,
  • Berit Bardarson, RN

      Affiliations

    • Department of Biostatistics, University of Washington, Seattle, WA
    • ,
  • Graham Nichol, MD, MPH

      Affiliations

    • Department of Biostatistics, University of Washington, Seattle, WA
    • University of Washington Clinical Trial Center, University of Washington–Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
    • ,
  • Resuscitation Outcomes Consortium Investigators

Received 13 March 2009 ,Revised 19 June 2009 ,Accepted 22 July 2009.

References 

  1. Lerner EB, Moscati RM. The golden hour: scientific fact or medical “urban legend”?. Acad Emerg Med. 2001;8:758–760
  2. Sampalis JS, Denis R, Lavoie A, et al. Trauma care regionalization: a process-outcome evaluation. J Trauma. 1999;46:565–581
  3. Samplais JS, Lavoie A, Williams JI, et al. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993;34:252–261
  4. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS major trauma outcome study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178:1141–1152
  5. Pepe PE, Wyatt CH, Bickell WH, et al. The relationship between total prehospital time and outcome in hypotensive victims of penetrating injuries. Ann Emerg Med. 1987;16:293–297
  6. Petri RW, Dyer A, Lumpkin J. The effect of prehospital transport time on the mortality from traumatic injury. Prehosp Disaster Med. 1995;10:24–29
  7. Lerner EB, Billittier AJ, Dorn JM, et al. Is total out-of-hospital time a significant predictor of trauma patient mortality?. Acad Emerg Med. 2003;10:949–954
  8. Pons PT, Markovchick VJ. Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome?. J Emerg Med. 2002;23:43–48
  9. Di Bartolomeo S, Valent F, Rosolen V, et al. Are pre-hospital time and emergency department disposition time useful process indicators for trauma care in Italy?. Injury. 2007;38:305–311
  10. Osterwalder JJ. Can the “golden hour of shock” safely be extended in blunt polytrauma patients?. Prehosp Disaster Med. 2002;17:75–80
  11. Feero S, Hedges JR, Simmons E, et al. Does out-of-hospital EMS time affect trauma survival?. Am J Emerg Med. 1995;13:133–135
  12. Gervin AS, Fischer RP. The importance of prompt transport in salvage of patients with penetrating heart wounds. J Trauma. 1982;22:443–446
  13. Ivatury RR, Nallathambi MN, Roberge RJ, et al. Penetrating thoracic injuries: in-field stabilization versus prompt transport. J Trauma. 1987;27:1066–1072
  14. Clevenger FW, Yarborough DR, Reines HD. Resuscitative thoracotomy: the effect of field time on outcome. J Trauma. 1988;28:441–445
  15. Grossman DC, Kim A, MacDonald SC, et al. Urban-rural differences in prehospital care of major trauma. J Trauma. 1997;42:723–729
  16. Pons PT, Haukoos JS, Bludworth W, et al. Paramedic response time: does is affect patient survival?. Acad Emerg Med. 2005;12:594–600
  17. Blackwell TH, Kaufman JS. Response time effectiveness: comparison of response time and survival in an urban EMS system. Acad Emerg Med. 2002;9:288–295
  18. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community: importance of rapid provision and implications for program planning. JAMA. 1979;241:1905–1907
  19. De Maio VJ, Stiell IG, Wells GA, et al. Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates. Ann Emerg Med. 2003;42:242–250
  20. Ambulance crash-related injuries among emergency medical services workers—Unites States, 1991-2002. MMWR Morb Mortal Wkly Rep. 2003;52:154–156
  21. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care. 2001;5:261–269
  22. Becker LR, Zaloshnja E, Levick N, et al. Relative risk of injury and death in ambulances and other emergency vehicles. Accid Anal Prev. 2003;35:941–948
  23. Newgard CD, Sears GK, Rea TD, et al. The Resuscitation Outcomes Consortium Epistry-Trauma: design, development, and implementation of a North American epidemiologic out-of-hospital trauma registry. Resuscitation. 2008;78:170–178
  24. Davis DP, Garberson LA, Andrusiekc D, et al. A descriptive analysis of emergency medical service systems participating in a large, out-of-hospital resuscitation research network. Prehosp Emerg Care. 2007;11:369–382
  25. Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2006;
  26. Cottington EM, Young JC, Shufflebarger CM, et al. The utility of physiologic status, injury site, and injury mechanism in identifying patients with major trauma. J Trauma. 1988;28:305–311
  27. Esposito TJ, Offner PJ, Jurkovich GJ, et al. Do prehospital trauma center triage criteria identify major trauma victims?. Arch Surg. 1995;130:171–176
  28. Kane G, Engelhardt R, Celentano J, et al. Empirical development and evaluation of out of hospital trauma triage instruments. J Trauma. 1985;25:482–489
  29. Norcross ED, Ford DW, Cooper ME, et al. Application of American College of Surgeons' field triage guidelines by pre-hospital personnel. J Am Coll Surg. 1995;181:539–544
  30. Henry MC, Hollander JE, Alicandro JM, et al. Incremental benefit of individual American College of Surgeons trauma triage criteria. Acad Emerg Med. 1996;3:992–1000
  31. Hannan EL, Farrell LS, Cooper A, et al. Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers?. J Am Coll Surg. 2005;200:584–592
  32. Baxt WG, Jones G, Fortlage D. The Trauma Triage Rule: a new, resource-based approach to the out-of-hospital identification of major trauma victims. Ann Emerg Med. 1990;19:1401–1406
  33. Zechnich AD, Hedges JR, Spackman K, et al. Applying the trauma triage rule to blunt trauma patients. Acad Emerg Med. 1995;2:1043–1052
  34. Lerner EB. Studies evaluating current field triage: 1966-2005. Prehosp Emerg Care. 2006;10:303–306
  35. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366–378
  36. Spaite DW, Valenzuela TD, Meislin HW, et al. Prospective validation of a new model for evaluating emergency medical services systems by in-field observation of specific time intervals in prehospital care. Ann Emerg Med. 1993;22:638–645
  37. Martens EP, Pestman WR, de Boer A, et al. Instrumental variables applications and limitations. Epidemiology. 2006;17:260–267
  38. McClellan M, McNeil BJ, Newhouse JP. Does more intensive treatment of acute myocardial infarction in the elderly reduce mortality?. JAMA. 1994;272:859–866
  39. Stock JH, Wright JH, Yogo M. A survey of weak instruments and weak identification in generalized methods of moments. 2002. J Business Econ Stat. 2002;20:518–529
  40. Pracht EE, Tepas JJ, Celso BG, et al. Survival advantage associated with treatment of injury at designated trauma centers: a bivariate probit model with instrumental variables. Med Care Res Rev. 2007;64:83–97
  41. McConnell J, Newgard CD, Mullins RJ, et al. Mortality benefit of transfer to level I versus level II trauma centers for head-injured patients: analysis using instrumental variables. Health Serv Res. 2005;40:435–457
  42. Wears RL. Advanced statistics: statistical methods for analyzing cluster and cluster-randomized data. Acad Emerg Med. 2002;9:330–341
  43. Brasel KJ, Bulger E, Cook AJ, et al. Hypertonic resuscitation: design and implementation of a prehospital intervention trial. J Am Coll Surg. 2008;206:220–232
  44. Spaite DW, Tse DJ, Valenzuela TD, et al. The impact of injury severity and prehospital procedures on scene time in victims of major trauma. Ann Emerg Med. 1991;20:1299–1305
  45. Carr BG, Caplan JM, Pryor JP, et al. A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care. 2006;10:198–206
  46. Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA. 1994;271:1919–1924
  47. Mullins RJ, Veum-Stone J, Hedges JR, et al. Influence of a statewide trauma system on location of hospitalization and outcome of injured patients. J Trauma. 1996;40:536–545
  48. Mullins RJ, Mann NC, Hedges JR, et al. Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. J Trauma. 1998;44:609–617
  49. Demetriades D, Martin M, Salim A, et al. The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Ann Surg. 2005;242:512–519
  50. Liberman M, Mulder D, Samplais J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma. 2000;49:584–599
  51. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105–1109
  52. Wang HE, Peitzman AB, Cassidy LD, et al. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med. 2004;44:439–450
  53. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;54:444–453
  54. Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we?. Ann Emerg Med. 2006;47:532–541
  55. Birk HO, Henriksen LO. Prehospital interventions: on-scene time and ambulance technicians' experience. Prehosp Disaster Med. 2002;17:167–169
  56. Cudnik M, Newgard CD, Wang H, et al. Endotracheal intubation increases out of hospital time in trauma patients. Prehosp Emerg Care. 2007;11:224–229
  57. Sloan EP, Callahan EP, Duda J, et al. The effect of urban trauma system hospital bypass on prehospital transport times and level 1 trauma patient survival. Ann Emerg Med. 1989;18:1146–1150
  58. Wang HE, Faibanks RJ, Shah MN, et al. Tort claims and adverse events in emergency medical services. Ann Emerg Med. 2008;52:256–262

 Supervising editor: Daniel W. Spaite, MD

 Author contributions: CDN conceived of and designed the study. RS performed the database management, quality assurance of the data, and all statistical analyses. CDN, RS, JRH, JPT, DPD, EMB, and GN interpreted preliminary findings and assisted in refining the final analysis. CDN drafted the article, and all authors contributed substantially to its revision. RS takes responsibility for data quality and all analyses. CDN takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The Resuscitation Outcome Consortium was supported by a series of cooperative agreements to 10 regional clinical centers and 1 data coordinating center (5U01 HL077863, HL077881, HL077871, HL077872, HL077866, HL077908, HL077867, HL077885, HL077877, HL077873) from the National Heart, Lung, and Blood Institute, in partnership with the National Institute of Neurological Disorders and Stroke, US Army Medical Research and Material Command, the Canadian Institutes of Health Research-Institute of Circulatory and Respiratory Health, Defence Research and Development Canada, the Heart and Stroke Foundation of Canada, and the American Heart Association.

 Publication date: Available online September 22, 2009.

 Reprints not available from the authors.

 Provide feedback on this article at the journal's Web site, www.annemergmed.com.

 Please see page 236 for the Editor's Capsule Summary of this article.

PII: S0196-0644(09)01284-0

doi: 10.1016/j.annemergmed.2009.07.024

Annals of Emergency Medicine
Volume 55, Issue 3 , Pages 235-246.e4 , March 2010

Article Tools

* Image Usage & Resolution