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Tccc Newgard Golden Hour Annals of Emerg Med 2010

Tccc Newgard Golden Hour Annals of Emerg Med 2010

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EMERGENCY MEDICAL SERVICES/ORIGINAL RESEARCH
Emergency Medical Services Intervals and Survival in Trauma:Assessment
of
the "Golden Hour" in a
North
American
Craig D. Newgard, MD, MPHRobert H. Schmicker, MSJerris
R.
Hedges, MD, MS,
MMM
John P. Trickett, BScNDaniel P. Davis, MDEileen M.
BUlger,
MDTom P. Aufderheide, MDJoseph P. Minei, MDJ. Steven Hata, MD,
FCCP,
MSc
K.
Dean Gubler, DO, MPHTodd B. Brown, MD, MSPHJean-Denis Yelle, MDBerit Bardarson, RNGraham Nichol, MD, MPHand the Resuscitation OutcomesConsortium Investigators
Prospective Cohort
From
the Center for
Policy
and
Research
in
Emergency
Medicine, Department of
Emergency
Medicine,
Oregon
Health
&
Science
University,
Portland,
OR
(Newgard);
theDepartmentofBiostatistics(Schmicker, Bardarson,
Nichol).
Departmentof
Surgery
(Bulger),
and University of
Washington Clinical
TrialCenter,University of Washington-Harborview Centerfor Prehospital
Emergency
Care
(Nichol).
UniversityofWashington, Seattle,
WA;
the Departmentof Medicine,JohnA.Burns
School
ofMedicine,Universityof Hawaii-Manoa,
Honolulu,
HI
(Hedges);
the Department of
Emergency
Medicine
(Trickett)and Department of
Surgery (Yelle),
University
of
Ottawa,
Ottawa, Ontario,
Canada;
the
Department
of
Emergency
Medicine, UniversityofCaliforniaatSan
Diego,
SanDiego,CA
(Davis);
theDepartmentof
Emergency
Medicine,
Medical
College
of Wisconsin, Milwaukee.
WI
(Aufderheide);
the Department of
Surgery,
University of
Texas
Southwestern MedicalCenter,Dallas,
TX
(Minei);the Department ofAnesthesia,DivisionofCritical
Care,
UniversityofIowa,IowaCity,IA
(Hata);
the
LegacyEmanuel
Trauma
Program,
Portland,
OR
(Gubler);
and Department of
Emergency
Medicine.
University
of
Alabama
at Birmingham, Birmingham, AL
(Brown).
Study
obJective:
The first hour after the
onset
of out-of-hospital traumatic injury is referred to as the "goldenhour," yet the relationship between
time
and outcome remains unclear. We evaluate the association betweenemergency medical services (EMS) intervals and mortality among trauma patients with tteld-based physiologicabnormality.
Methods:
This was a secondary
analysis
of an out-of-hospital, prospective
cohort
registry of
adult
(aged
~ 1 5
 
years)
trauma patients transported
by
146
EMS agencies
to
51 Level
I
and
1\
traumahospitals
in
10
sites
across North America
from
December 1,
2005,
through March
31,
2007.
Inclusion criteria weresystolic 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. Theoutcome was in
hospital
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-basedconfounders.
Results:
There were
3,656
trauma
patients available for analysis, of whom
806
(22.0%) died. In multivariableanalyses, there was no significant association between time and mortality for any EMS interval: activation (oddsratio
[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 mortalityamong injured patients with physiologic abnormality in the field. [Ann Emerg Med.
2010;55:235-246.]
Please see page
236
for the Editor's Capsule Summary of this article.
Provide
feedback
on this article at the journal's
Web
site.
www.annemergmed.com.
0196-0644/$-see front matter
Copyright
©
2009 by the
American
College
of
Emergency
Physicians.
doi:10.1016 /j.annemergmed. 2009.07.024Volume
55,
NO.3
March
2010
Annals
of
Emergency Medicine
235
 
Out-of-Hospital
Time
and Survival
Newgard
et
at
Editor's Capsule
Summary
Whatis
already
known
on
this topic
The
"golden hour" concept in
trauma
is pervasivedespite little evidence to
support
it.
What
question
thisstudy
addressed
Is there an association between various emergencymedical services
(EMS)
intervals
and
inhospitalmortality in seriously injured adults?
What
this
study
adds
to our
k n o w l e d g ~
 
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.
Howthismight
change
clinical
practice
This study suggests
that
in
our
current out-ofhospital
and
emergency care system time may be lesscrucial than once thought. Routine
n g h t s ~ a n d - s i r e n s
 
transport
for
trauma
patients,
with
its inherent risks,may
not
be warranted.
INTRODUCTION
Background
The
first 60 minutes after traumatic injury has been termedthe "golden hour.,,1
The
concept that definitive trauma caremust be initiated within this 60-minute window has beenpromulgated, taught, and practiced for more than 3 decades; thebelief that injury outcomes improve with a reduction in time todefinitive care is a basic premise
of
trauma systems andemergency medical services (EMS) systems. However, there islittle evidence to directly
suppon
this
relationship.'
Two studiesfrom Quebec suggested that increased total out-of-hospital
(ie,
EMS) time was associated with increased mortality amongseriously injured trauma patients,2.3 yet this finding has
not
been replicated in other
seuings"!"
Additional studiessuggesting a link berween out-of-hospital time and outcomehave been tempered by indirect comparisons,
1\
small samples
of
highly selected surgical patients,12-14 rural trauma patients withlong EMS response
tirnes.l?
and
mixed samples that includedpatients with nontraumatic cardiacarrest.'
G.17
Importance
To date, patients with out-of-hospital cardiac arrest remainthe only field-based patient population with a consistentassociationberweentime (responseinterval) andsurvival.
18.!9
Despite the paucity
of
outcome evidence supporting rapidout-of-hospital times for the broader population
of
patientsactivating the 911 system, EMS agencies in
North
America aregenerally held
to
strict standards about intervals, particularly theresponse interval. Meeting such expectations requirescomprehensive emergency vehicle and personnel coveragethroughout a community and travel at high speeds in riskytraffic situations (eg, intersections) that occasionally result incrashes causing injury and death to emergency vehicle occupantsand others.
20.22
Demonstrating the benefit
of
such timestandards in noncardiac arrest patients is important in justifyingthe resources and risks inherent in meeting such goals in EMSsystems. Previous studies assessing the time-outcome associationin trauma have been limited by heterogeneous patient groups,single EMS agencies, small sample sizes, and the exclusion
of
patients who died in the field.
Goals
of
This Investigation
In this study, we tested the association berween EMSintervals and mortality among trauma patients known to be athigh risk of adverse outcomes (those with field-basedphysiologic abnormality) in 146 diverse EMS agencies across 10
North
American sites. Patients who died in the field were alsoexamined as a subset
of
this population.
MATERIALS AND
METHODS
Study Design
This was a secondary analysis of an out-of-hospital,consecutive-patient, prospective cohort registry of injuredpersons with field-based physiologic abnormality.
Setting
These data were collected as part
of
the ResuscitationOutcomes Consortium epidemiologic out-of-hospital traumaregistry (the Resuscitation Outcomes Consortium
Epistry
Trauma)?3
The
primary sample for this study was collectedfrom December
1,2005,
through March
31,2007.
Eligiblepatients were identified from 146 EMS agencies (ground and airmedical) transporting to 51 Level
I
and
II
trauma hospitals in10 sites across the United States and Canada (Birmingham,
AL;
Dallas,
TX;
Iowa; Milwaukee,
WI;
Pittsburgh, PA; Portland,OR; King County, WA; Ottawa,
ON;
Toronto,
ON;
andVancouver, BC).
The
sites vary in size, location, and EMSsystem structure and provide care to injured persons fromdiverse urban, suburban, rural, and frontier
regions.f"
One
hundred fifty-three institutional review boards/research ethicsboards (127 hospital-based and 26 EMS agency-based) in boththe United States and Canada reviewed and approved theResuscitation Outcomes Consortium Epistry-Trauma projectand waived the requirement for informed consent.
Selection
of
Participants
The
primary study cohort consisted
of
consecutive injuredadults (aged
~
 
15 years) requiring activation
of
the emergency911 system within predefined geographic regions at eachResuscitation Outcomes Consortium site. For the primarysample, patients must have been evaluated by an
EMS
provider,had signs of physiologic abnormality at any point during out-of236
Annals
of
Emergency Medicine Volume
55,
NO.3:
March
2010
 
Newgard
et
at
Out-of-Hospital Time and Survivalhospital evaluation, and required EMS transport to a hospital.
The
definition for out-of-hospital physiologic abnormality wasbased on the American College
of
Surgeons Committee onTrauma Field Triage Decision Scheme "Step 1"
crireria/?
thathave been demonstrated
to
have high specificity for identifyingpatients with serious injury
and
need for specialized traumaresources.2
6-
34
Injured patients with
one
or more
of
thefollowing criteria were included: systolic blood pressure (SBP)less than or equal to 90 mm Hg, Glasgow
Coma
Scale (GCS)score less than or equal to 12, respiratory rate less than 10 orgreater than 29 breaths/min, or advanced airway intervention(tracheal intubation, supraglottic airway, or cricothyrotomy)."Injury" was broadly defined as any blunt, penetrating, or burnmechanism for which the EMS
providerfs)
believed trauma tobe the primary clinical insult.
The
primary analysis included patients transported directlyto trauma centers
to
minimize the effect
of
hospital type(trauma versus nontraurna hospitals) on
outcome.Y
Injuredpersons who were not transported by EMS (ie, died in the fieldwith or without resuscitative measures, refused transport, orwere not otherwise transported by EMS) were excluded fromthe primary analysis because certain out-of-hospital intervals(on-scene, transport, total out-of-hospital) could not becalculated. Children (aged
<
15 years) were excluded because ofdifferent responses to injury, different "normal" physiologicranges compared with those
of
adults, and age-based variabilityin EMS procedure use (eg, tracheal intubation). Although thesepatients groups were excluded from the primary analysis,information on such patients was collected during the sameperiod and included in sensitivity analyses to better understandhow the broader inclusion
of
such injury patients may affectstudy results.Patients enrolled in a concurrent clinical trial withembargoed outcomes (Hypertonic Resuscitation FollowingTraumaticInjury,ClinicalTrials.govidentifiers N
CT003160
17and NCT00316004) were also excluded from the TraumaEpistry database.
Data Collection and Processing
The
process used for data collection in ResuscitationOutcomes Consortium Epistry-Trauma has been described indetail
elsewhere.f'
In brief, each Resuscitation OutcomesConsortium site identified eligible out-of-hospital traumapatients from participating EMS agencies. Standardized datawere collected from each agency, processed locally, entered intostandardized data forms, matched to hospital outcomes,deidentified, and submitted
to
a central data coordinating center(Seattle, WA). Quality assurance processes included EMSprovider data collection training, data element range andconsistency checks, and annual site visits to review randomlyselected study records, data capture processes, and local dataquality efforts. Sites and agencies that had substantially higheror lower monthly case capture (relative
to
their average), asdetermined with a Poisson distribution with a 5% cutoff, weresent inquiries to reduce biased sampling.
The
dates forenrollment and resulting sample size were based on the initialinception
of
the Resuscitation Outcomes Consortium EpistryTrauma database (December 1, 2005) through the most recentdate demonstrating complete case capture and a high
level
of
outcome completion (March 31, 2007).
Methods
of
Measurement
EMS intervals were calculated from dispatch records and allavailable out-of-hospital patient care reports. For patients withmultiple sources
of
time records (eg, dispatch, 2 or more patientcare reports from different EMS agencies), discrepancies wereresolved between data sources to produce the most accuraterepresentation of true times. Intervals were based on standardEMS definitions, including activation interval (time 911 callreceived at dispatch
to
alarm activation at EMS first responseagency), response interval (time from alarm activation to arrival
of
first responding vehicle on scene), on-scene interval (timearrival
of
first EMS responding vehicle on scene until leavingthe scene), and transport interval (time leaving the scene tovehicle arrival at the receiving hospital).36 We defined the totalEMS interval as time from 911 call received to arrival at thereceiving hospital. This definition was used to approximate theinterval from time
of
injury to time of definitive care andrepresents a slightly longer duration than the "total out-ofhospital interval" defined by Spaite et al.36Time at patient'sside and time
of
care transfer in the hospital were notconsistently captured by all sites and were therefore not availablein this study. We considered all intervals as continuouscovariates but also evaluated categorical versions of total EMStime (:560 versus
>60
minutes) and response interval
«4,4
to8, and
>8)
according
to
previously defined response intervalsfor cardiac arrest.
1B19
Fourteen additional out-of-hospital variables were consideredin the analysis. Physiologic information included the initial (ie,preintervention) field values (SBP [rnrn Hg], GCS score,respiratory rate [breaths/min], shock index [pulse rate/SBP])and use advanced airway procedures (tracheal intubation and"rescue" airways [supraglottic airway or cricothyrotomy]). SBP
«90,
150 to 179, and
2:
180 mm Hg; reference 90 to 149 mmHg) and respiratory rate « 10 and
>29
breaths/min; reference10 to 29 breaths/min) were categorized to allow for nonlinearassociations with outcome.
The
"worst" physiologic values (eg,lowest GCS score) were also assessed to account for the portion
of
patients with repeated vital sign measurements thatdemonstrated physiologic decompensation after initial fieldassessment. Additional variables included age (years), sex,mechanism of injury (motor vehicle, motorcycle, pedal cyclist,pedestrian, other transport, fall, struck by/against, stabbing,firearm, machinery, burn, natural/environment, other), type ofinjury (blunt versus penetrating), trauma hospital level
(I
versusII), use of intravenous or intraosseous fluids, hemorrhagecontrol (ie, compression), mode of transport (groundambulance versus helicopter), EMS service level
of
firstresponding vehicle (advanced versus basic life support), and site.
Volume
55,
NO.3:
March
2010
Annals
of
Emergency Medicine
237

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