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

      Study objective

      The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality.

      Methods

      This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders.

      Results

      There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings.

      Conclusion

      In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.
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      References

        • Lerner E.B.
        • Moscati R.M.
        The golden hour: scientific fact or medical “urban legend”?.
        Acad Emerg Med. 2001; 8: 758-760
        • Sampalis J.S.
        • Denis R.
        • Lavoie A.
        • et al.
        Trauma care regionalization: a process-outcome evaluation.
        J Trauma. 1999; 46: 565-581
        • Samplais J.S.
        • Lavoie A.
        • Williams J.I.
        • 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
        • Stiell I.G.
        • Nesbitt L.P.
        • Pickett W.
        • et al.
        The OPALS major trauma outcome study: impact of advanced life-support on survival and morbidity.
        CMAJ. 2008; 178: 1141-1152
        • Pepe P.E.
        • Wyatt C.H.
        • Bickell W.H.
        • et al.
        The relationship between total prehospital time and outcome in hypotensive victims of penetrating injuries.
        Ann Emerg Med. 1987; 16: 293-297
        • Petri R.W.
        • Dyer A.
        • Lumpkin J.
        The effect of prehospital transport time on the mortality from traumatic injury.
        Prehosp Disaster Med. 1995; 10: 24-29
        • Lerner E.B.
        • Billittier A.J.
        • Dorn J.M.
        • et al.
        Is total out-of-hospital time a significant predictor of trauma patient mortality?.
        Acad Emerg Med. 2003; 10: 949-954
        • Pons P.T.
        • Markovchick V.J.
        Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome?.
        J Emerg Med. 2002; 23: 43-48
        • 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
        • Osterwalder J.J.
        Can the “golden hour of shock” safely be extended in blunt polytrauma patients?.
        Prehosp Disaster Med. 2002; 17: 75-80
        • Feero S.
        • Hedges J.R.
        • Simmons E.
        • et al.
        Does out-of-hospital EMS time affect trauma survival?.
        Am J Emerg Med. 1995; 13: 133-135
        • Gervin A.S.
        • Fischer R.P.
        The importance of prompt transport in salvage of patients with penetrating heart wounds.
        J Trauma. 1982; 22: 443-446
        • Ivatury R.R.
        • Nallathambi M.N.
        • Roberge R.J.
        • et al.
        Penetrating thoracic injuries: in-field stabilization versus prompt transport.
        J Trauma. 1987; 27: 1066-1072
        • Clevenger F.W.
        • Yarborough D.R.
        • Reines H.D.
        Resuscitative thoracotomy: the effect of field time on outcome.
        J Trauma. 1988; 28: 441-445
        • Grossman D.C.
        • Kim A.
        • MacDonald S.C.
        • et al.
        Urban-rural differences in prehospital care of major trauma.
        J Trauma. 1997; 42: 723-729
        • Pons P.T.
        • Haukoos J.S.
        • Bludworth W.
        • et al.
        Paramedic response time: does is affect patient survival?.
        Acad Emerg Med. 2005; 12: 594-600
        • Blackwell T.H.
        • Kaufman J.S.
        Response time effectiveness: comparison of response time and survival in an urban EMS system.
        Acad Emerg Med. 2002; 9: 288-295
        • Eisenberg M.S.
        • Bergner L.
        • Hallstrom A.
        Cardiac resuscitation in the community: importance of rapid provision and implications for program planning.
        JAMA. 1979; 241: 1905-1907
        • De Maio V.J.
        • Stiell I.G.
        • Wells G.A.
        • et al.
        Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates.
        Ann Emerg Med. 2003; 42: 242-250
      1. Ambulance crash-related injuries among emergency medical services workers—Unites States, 1991-2002.
        MMWR Morb Mortal Wkly Rep. 2003; 52: 154-156
        • Kahn C.A.
        • Pirrallo R.G.
        • Kuhn E.M.
        Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis.
        Prehosp Emerg Care. 2001; 5: 261-269
        • Becker L.R.
        • 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
        • Newgard C.D.
        • Sears G.K.
        • Rea T.D.
        • 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
        • Davis D.P.
        • Garberson L.A.
        • 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
        • Committee on Trauma
        Resources for Optimal Care of the Injured Patient.
        American College of Surgeons, Chicago, IL2006
        • Cottington E.M.
        • Young J.C.
        • Shufflebarger C.M.
        • et al.
        The utility of physiologic status, injury site, and injury mechanism in identifying patients with major trauma.
        J Trauma. 1988; 28: 305-311
        • Esposito T.J.
        • Offner P.J.
        • Jurkovich G.J.
        • et al.
        Do prehospital trauma center triage criteria identify major trauma victims?.
        Arch Surg. 1995; 130: 171-176
        • 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
        • Norcross E.D.
        • Ford D.W.
        • Cooper M.E.
        • et al.
        Application of American College of Surgeons' field triage guidelines by pre-hospital personnel.
        J Am Coll Surg. 1995; 181: 539-544
        • Henry M.C.
        • Hollander J.E.
        • Alicandro J.M.
        • et al.
        Incremental benefit of individual American College of Surgeons trauma triage criteria.
        Acad Emerg Med. 1996; 3: 992-1000
        • Hannan E.L.
        • Farrell L.S.
        • 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
        • Baxt W.G.
        • 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
        • Zechnich A.D.
        • Hedges J.R.
        • Spackman K.
        • et al.
        Applying the trauma triage rule to blunt trauma patients.
        Acad Emerg Med. 1995; 2: 1043-1052
        • Lerner E.B.
        Studies evaluating current field triage: 1966-2005.
        Prehosp Emerg Care. 2006; 10: 303-306
        • MacKenzie E.J.
        • Rivara F.P.
        • Jurkovich G.J.
        • et al.
        A national evaluation of the effect of trauma-center care on mortality.
        N Engl J Med. 2006; 354: 366-378
        • Spaite D.W.
        • Valenzuela T.D.
        • Meislin H.W.
        • 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
        • Martens E.P.
        • Pestman W.R.
        • de Boer A.
        • et al.
        Instrumental variables applications and limitations.
        Epidemiology. 2006; 17: 260-267
        • McClellan M.
        • McNeil B.J.
        • Newhouse J.P.
        Does more intensive treatment of acute myocardial infarction in the elderly reduce mortality?.
        JAMA. 1994; 272: 859-866
        • Stock J.H.
        • Wright J.H.
        • Yogo M.
        A survey of weak instruments and weak identification in generalized methods of moments. 2002.
        J Business Econ Stat. 2002; 20: 518-529
        • Pracht E.E.
        • Tepas J.J.
        • Celso B.G.
        • 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
        • McConnell J.
        • Newgard C.D.
        • Mullins R.J.
        • 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
        • Wears R.L.
        Advanced statistics: statistical methods for analyzing cluster and cluster-randomized data.
        Acad Emerg Med. 2002; 9: 330-341
        • Brasel K.J.
        • Bulger E.
        • Cook A.J.
        • et al.
        Hypertonic resuscitation: design and implementation of a prehospital intervention trial.
        J Am Coll Surg. 2008; 206: 220-232
        • Spaite D.W.
        • Tse D.J.
        • Valenzuela T.D.
        • 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
        • Carr B.G.
        • Caplan J.M.
        • Pryor J.P.
        • et al.
        A meta-analysis of prehospital care times for trauma.
        Prehosp Emerg Care. 2006; 10: 198-206
        • Mullins R.J.
        • 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
        • Mullins R.J.
        • Veum-Stone J.
        • Hedges J.R.
        • et al.
        Influence of a statewide trauma system on location of hospitalization and outcome of injured patients.
        J Trauma. 1996; 40: 536-545
        • Mullins R.J.
        • Mann N.C.
        • Hedges J.R.
        • et al.
        Preferential benefit of implementation of a statewide trauma system in one of two adjacent states.
        J Trauma. 1998; 44: 609-617
        • 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
        • 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
        • Bickell W.H.
        • Wall M.J.
        • Pepe P.E.
        • et al.
        Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.
        N Engl J Med. 1994; 331: 1105-1109
        • Wang H.E.
        • Peitzman A.B.
        • Cassidy L.D.
        • et al.
        Out-of-hospital endotracheal intubation and outcome after traumatic brain injury.
        Ann Emerg Med. 2004; 44: 439-450
        • Davis D.P.
        • Hoyt D.B.
        • 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
        • Wang H.E.
        • Yealy D.M.
        Out-of-hospital endotracheal intubation: where are we?.
        Ann Emerg Med. 2006; 47: 532-541
        • Birk H.O.
        • Henriksen L.O.
        Prehospital interventions: on-scene time and ambulance technicians' experience.
        Prehosp Disaster Med. 2002; 17: 167-169
        • Cudnik M.
        • Newgard C.D.
        • Wang H.
        • et al.
        Endotracheal intubation increases out of hospital time in trauma patients.
        Prehosp Emerg Care. 2007; 11: 224-229
        • Sloan E.P.
        • Callahan E.P.
        • 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
        • Wang H.E.
        • Faibanks R.J.
        • Shah M.N.
        • et al.
        Tort claims and adverse events in emergency medical services.
        Ann Emerg Med. 2008; 52: 256-262

      Linked Article

      • Have We Killed the Golden Hour of Trauma?
        Annals of Emergency MedicineVol. 57Issue 1
        • Preview
          The study by Newgard et al1 in the March issue of Annals proposed to set the record straight on the “golden hour” of trauma, one of the best-holding dogmas in medicine.2 They measured the association between emergency medical services (EMS) intervals and mortality among 3,656 trauma patients with substantial abnormal vital signs/mental status, transported by 146 EMS agencies to 51 trauma centers across the United States and Canada. They found no correlation. The associated capsule mentioned that “… time may be less crucial than once thought.  
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