Out-of-Hospital Time and Survivalhospital evaluation, and required EMS transport to a hospital.
definition for out-of-hospital physiologic abnormality wasbased on the American College
Surgeons Committee onTrauma Field Triage Decision Scheme "Step 1"
thathave been demonstrated
have high specificity for identifyingpatients with serious injury
need for specialized traumaresources.2
Injured patients with
thefollowing criteria were included: systolic blood pressure (SBP)less than or equal to 90 mm Hg, Glasgow
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
believed trauma tobe the primary clinical insult.
primary analysis included patients transported directlyto trauma centers
minimize the effect
hospital type(trauma versus nontraurna hospitals) on
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
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
such injury patients may affectstudy results.Patients enrolled in a concurrent clinical trial withembargoed outcomes (Hypertonic Resuscitation FollowingTraumaticInjury,ClinicalTrials.govidentifiers N
17and NCT00316004) were also excluded from the TraumaEpistry database.
Data Collection and Processing
process used for data collection in ResuscitationOutcomes Consortium Epistry-Trauma has been described indetail
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
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
their average), asdetermined with a Poisson distribution with a 5% cutoff, weresent inquiries to reduce biased sampling.
dates forenrollment and resulting sample size were based on the initialinception
the Resuscitation Outcomes Consortium EpistryTrauma database (December 1, 2005) through the most recentdate demonstrating complete case capture and a high
outcome completion (March 31, 2007).
EMS intervals were calculated from dispatch records and allavailable out-of-hospital patient care reports. For patients withmultiple sources
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
alarm activation at EMS first responseagency), response interval (time from alarm activation to arrival
first responding vehicle on scene), on-scene interval (timearrival
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
injury to time of definitive care andrepresents a slightly longer duration than the "total out-ofhospital interval" defined by Spaite et al.36Time at patient'sside and time
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
minutes) and response interval
previously defined response intervalsfor cardiac arrest.
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
150 to 179, and
180 mm Hg; reference 90 to 149 mmHg) and respiratory rate « 10 and
breaths/min; reference10 to 29 breaths/min) were categorized to allow for nonlinearassociations with outcome.
"worst" physiologic values (eg,lowest GCS score) were also assessed to account for the portion
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
versusII), use of intravenous or intraosseous fluids, hemorrhagecontrol (ie, compression), mode of transport (groundambulance versus helicopter), EMS service level
firstresponding vehicle (advanced versus basic life support), and site.