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Emergency Medical Services Intervals and Survival in Trauma
Dr. Miramonti asked me to post an abstract of this study that was published in the March 2010 issue of The Annals of Emergency Medicine. It is an interesting study that evaluates the importance of the golden hour of trauma. This is not an indication of a system wide priority change, or intended to adjust current trauma responses- it’s merely a discussion topic. Let me know what you think.
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.
Editor’s Capsule Summary:
What is already known on this topic
The “golden hour” concept in trauma is pervasive despite little evidence to support it.
What question this study addressed
Is there an association between various emergency medical services (EMS) intervals and inhospital mortality in seriously injured adults?
What this study adds to our knowledge
In 3,656 injured patients with substantial perturbations of vital signs or mental status, transported by 146 EMS agencies to 51 trauma centers across North America, no association was found among any EMS interval and mortality.
How this might change clinical practice
This study suggests that in our current out-of- hospital and emergency care system time may be less crucial than once thought. Routine lights-and-sirens transport for trauma patients, with its inherent risks, may not be warranted.
Abstract Reference:
Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort
Craig D. Newgard, Robert H. Schmicker, Jerris R. Hedges, John P. Trickett, Daniel P. Davis, Eileen M. Bulger, Tom P. Aufderheide, Joseph P. Minei, J. Steven Hata, K. Dean Gubler, Todd B. Brown, Jean-Denis Yelle, Berit Bardarson, Graham Nichol
Annals of emergency medicine 1 March 2010 (volume 55 issue 3 Pages 235-246.e4 DOI: 10.1016/j.annemergmed.2009.07.024)
This is a facinating study. In my 32 years in EMS I have always thought first responder care was more critical than speed. I believe some studys in the current battlefields have shown, for example, that on scene bleeding control has a much better outcome than rapid, thus dangerous transport. This is one reason new battlefield uniforms are being made with built in tourniquets for self application.
Certainly food for thought.