Association between prehospital time and injury severity in traffic crash patients.

Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality. All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association. We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality. A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality. Prognostic and Epidemiologic; level III.

Prehospital Time Following Traumatic Injury Is Independently Associated With the Need for In-Hospital Blood and Early Mortality for Specific Injury Types

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71–1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03–1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.

Background Prehospital care for traumatic brain injury (TBI) is important to prevent secondary brain injury. We aim to compare prehospital care systems within Europe and investigate the association of system characteristics with the stability of patients at hospital arrival. Methods We studied TBI patients who were transported to CENTER-TBI centers, a pan-European, prospective TBI cohort study, by emergency medical services between 2014 and 2017. The association of demographic factors, injury severity, situational factors, and interventions associated with on-scene time was assessed using linear regression. We used mixed effects models to investigate the case mix adjusted variation between countries in prehospital times and interventions. The case mix adjusted impact of on-scene time and interventions on hypoxia (oxygen saturation <90%) and hypotension (systolic blood pressure <100mmHg) at hospital arrival was analyzed with logistic regression. Results Among 3878 patients, the greatest driver of longer on-scene time was intubation (+8.3 min, 95% CI: 5.6–11.1). Secondary referral was associated with shorter on-scene time (-5.0 min 95% CI: −6.2– −3.8). Between countries, there was a large variation in response (range: 12–25 min), on-scene (range: 16-36 min) and travel time (range: 15–32 min) and in prehospital interventions. These variations were not explained by patient factors such as conscious level or severity of injury (expected OR between countries: 1.8 for intubation, 1.8 for IV fluids, 2.0 for helicopter). On-scene time was not associated with the regional EMS policy (p= 0.58). Hypotension and/or hypoxia were seen in 180 (6%) and 97 (3%) patients in the overall cohort and in 13% and 7% of patients with severe TBI (GCS <8). The largest association with secondary insults at hospital arrival was with major extracranial injury: the OR was 3.6 (95% CI: 2.6–5.0) for hypotension and 4.4 (95% CI: 2.9–6.7) for hypoxia. Discussion Hypoxia and hypotension continue to occur in patients who suffer a TBI, and remain relatively common in severe TBI. Substantial variation in prehospital care exists for patients after TBI in Europe, which is only partially explained by patient factors.

The increase in mortality and total prehospital time (TPT) seen in Qatar appear to be realistic. However, existing reports on the influence of TPT on mortality in trauma patients are conflicting. This study aimed to explore the impact of prehospital time on the in-hospital outcomes. A retrospective analysis of data on patients transferred alive by Emergency Medical Services (EMS) and admitted to Hamad Trauma Center (HTC) of Hamad General Hospital (HGH; Doha, Qatar) from June 2017 through May 2018 was conducted. This study was centered on the National Trauma Registry database. Patients were categorized based on the trauma triage activation and prehospital intervals, and comparative analysis was performed. A total of 1,455 patients were included, of which nearly one-quarter of patients required urgent and life-saving care at a trauma center (T1 activations). The overall TPT was 70 minutes and the on-scene time (OST) was 24 minutes. When compared to T2 activations, T1 patients were more likely to have been involved in road traffic injuries (RTIs); experienced head and chest injuries; presented with higher Injury Severity Score (ISS: median = 22); and had prolonged OST (27 minutes) and reduced TPT (65 minutes; P = .001). Prolonged OST was found to be associated with higher mortality in T1 patients, whereas TPT was not associated. In-hospital mortality was independent of TPT but associated with longer OST in severely injured patients. The survival benefit may extend beyond the golden hour and may depend on the injury characteristics, prehospital, and in-hospital settings.

This study compared prehospital on-scene times (OSTs) for patients treated by nurse-staffed emergency medical services (EMS) with OST for patients treated by a combination of EMS and physician-staffed helicopter emergency medical services (HEMS). A secondary aim was to investigate the relationship between length of OST and mortality. All trauma patients treated in the priority 1 emergency room of a Level I trauma center between January 2002 and 2004 were included in the study. To determine OST and outcome, hospital and prehospital data were entered into the trauma registry. OSTs for EMS and combined EMS/HEMS-treated patients were compared using linear regression analysis. Logistic regression analysis was used to compare mortality rates. The number of trauma patients included for analysis was 1,457. Of these, 1,197 received EMS assistance only, whereas 260 patients received additional care by an HEMS physician. HEMS patients had longer mean OSTs (35.4 vs. 24.6 minutes; p < 0.001) and higher Injury Severity Scores (24 vs. 9; p < 0.001). After correction for patient and trauma characteristics, like the Revised Trauma Score, age, Injury Severity Scores, daytime/night-time, and mechanism of trauma, the difference in OSTs between the groups was 9 minutes (p < 0.001). Logistic regression analyses showed a higher uncorrected chance of dying with increasing OST by 10 minutes (OR, 1.2; p < 0.001). This apparent effect of OST on mortality was explained by patient and trauma characteristics (adjusted OR, 1.0; p = 0.89). Combined EMS/HEMS assistance at an injury scene is associated with longer OST. When corrected for severity of injury and patient characteristics, no influence of longer OST on mortality could be demonstrated.

BackgroundThe outcome of road traffic injury (RTI) is determined by duration of prehospital time, patient’s demographics, and the type of injury and its mechanism. During the emergency medical service (EMS) prehospital time interval, on-scene time should be minimized for early treatment. This study aimed to examine the factors influencing on-scene EMS time among RTI patients.MethodsWe evaluated 19,141 cases of traffic trauma recorded between April 2014 and March 2020 in the EMS database of the Nara Wide Area Fire Department and the prehospital database of the emergency Medical Alliance for Total Coordination of Healthcare (e-MATCH). To examine the association of the number of EMS phone calls until hospital acceptance, age ≥65 years, high-risk injury, vital signs, holiday, and nighttime (0:00–8:00) with on-scene time, a generalized linear mixed model with random effects for four study regions was conducted.ResultsEMS phone calls were the biggest factor, accounting for 5.69 minutes per call, and high-risk injury accounted for an additional 2.78 minutes. Holiday, nighttime, and age ≥65 years were also associated with increased on-scene time, but there were no significant vital sign variables for on-scene time, except for the level of consciousness. Regional differences were also noted based on random effects, with a maximum difference of 2 minutes among regions.ConclusionsThe number of EMS phone calls until hospital acceptance was the most significant influencing factor in reducing on-scene time, and high-risk injury accounted for up to an additional 2.78 minutes. Considering these factors, including regional differences, can help improve the regional EMS policies and outcomes of RTI patients.

Objective:Preclinical actions in the primary assessment of victims of blunt trauma may prolong the time to definitive clinical care. The aim of this study was to examine the duration of...

BackgroundMajor trauma is a leading cause of premature death and disability worldwide, and many healthcare systems seek to improve outcomes following severe injury with provision of pre-hospital critical care. Much research has focussed on the efficacy of pre-hospital critical care and advanced pre-hospital interventions, but less is known about how the structure of pre-hospital critical care services may influence response to major trauma. This study assessed the association between likelihood of pre-hospital critical care response in major trauma and factors important in the planning and development of those services: geographic isolation, time of day, and tasking mechanism.MethodsA local trauma registry, supported with data from the Trauma Audit and Research Network alongside additional information regarding pre-hospital management, identified patients sustaining major trauma admitted to Major Trauma Centres in the North of England. Data was extracted on location and time of incident, mechanism of injury, on-scene times, and presence or absence of pre-hospital critical care team. An isochrone map was constructed for 30-minute intervals to regional Major Trauma Centres, defining geographic isolation. Univariate logistic regression compared likelihood of pre-hospital critical care response to that of conventional ambulance response for varying degrees of geographic isolation, day or night period, and mechanism of injury, and multiple linear regression assessed the association between geographic isolation, service response and on-scene time.Results2619 incidents were included, with 23.3% attended by pre-hospital critical care teams. Compared to conventional ambulance services, pre-hospital critical care teams were more likely to respond major trauma in areas of greater geographic isolation (OR 1.42, 95% CI 1.30–1.55, p < 0.005). There were significant differences in the mechanism of injury attended and no significant difference in response by day or night period. Pre-hospital critical care team response and increasing geographic isolation was associated with longer on-scene times (p < 0.005).ConclusionPre-hospital critical care teams are more likely to respond to major trauma in areas of greater geographic isolation. Enhanced pre-hospital care may mitigate geographic inequalities when providing advanced interventions and transport of severely injured patients. There may be an unmet need for pre-hospital critical care response in areas close to major hospitals.

BackgroundTime is an important determinant of outcomes for individuals following trauma. Optimising prehospital trauma systems and care, such as (where appropriate) reducing prehospital times, and ensuring patients get to the...

BackgroundThe ‘Golden Hour’ emphasizes the importance of rapidly providing definitive care to trauma patients. Dispatch time, defined as the time it takes the Helicopter Emergency Medical Service (HEMS) to dispatch...

Is prehospital supplemental oxygen effective for acute stroke?

Prehospital time intervals and management of ischemic stroke patients.

Injury remains a major cause of death and disability worldwide, and places an enormous burden on countries with limited resources. The optimal way to reduce life-threatening injuries is through primary prevention efforts that decrease the incidence and severity of injuries. When prevention fails, however, it is often possible to minimize the consequences of injury through effective prehospital and hospital-based trauma care. Unfortunately, much of the world's population does not have access to prehospital trauma care, particularly in low income countries. In many parts of the world, few victims receive treatment at the scene and fewer still receive safe transport to the hospital in an ambulance. Transport, when available, is usually provided by relatives, untrained bystanders, commercial drivers (minibus, taxi or truck drivers), or by public safety officers (police and firefighters). Many high-income countries have developed technically complex and costly prehospital trauma care systems to provide care for acutely ill or injured patients. While these systems are impressive and they undoubtedly benefit some patients, there is little evidence that they are inherently superior to less costly systems that provide a more basic level of prehospital care. The start-up and maintenance costs of advanced life support systems place them out of the reach of all but a few countries, effectively eliminating them as a practical, sustainable option in many parts of the world. Expensive systems are not necessarily the best. With few exceptions, most advanced prehospital interventions have not been scientifically proven to be effective because the necessary randomized trials have not been conducted. In fact, most of the benefits of prehospital trauma care can be readily realized if basic, vital interventions are quickly and consistently applied, utilizing a country's existing resources and health-care infrastructure. Considerable good may be accomplished by ensuring that victims receive life-sustaining care within a few minutes of injury. Even in countries with limited resources, many lives may be saved and disabilities prevented by teaching individuals what to do at the scene of an injury. The foundations of an effective prehospital system can be laid by recruiting carefully selected volunteers and non-medical professionals, and providing them with training as well as the basic supplies and equipment they need to provide effective prehospital care. Most severely injured patients who die in the first few hours after injury succumb to airway compromise, respiratory failure or uncontrolled haemorrhage. All of these conditions can be treated using basic first aid measures. The challenge, however, is to promote sustainable and affordable prehospital trauma care systems that provide services to everyone. To do this, each system must be defined by local needs and capacity and must be developed with due regard for local culture and health-care capacity. …

Objective To analyze if pre-hospital rescue times were associated with mortality in a trauma cohort arriving by ambulance to hospital in a Scandinavian urban setting. Methods Between 2011 and 2013, individuals and pre-hospital rescue times were identified in Emergency Medical Dispatcher Centre, hospital, and forensic records in red alarm trauma. Major trauma was defined as a New Injury Severity Score (NISS)&gt;15. Results Overall, 89% of 378 trauma patients received hospital care within 60 min; 51% had a response time of ≤8 min, and 95% had response time within ≤20 min. The on-scene time (p &lt; 0.05) and total pre-hospital time (p &lt; 0.05) were longer for patients ≥65 years, in comparison with patients &lt;65 years. The patients with penetrating trauma had shorter on-scene time (p &lt; 0.01), total pre-hospital time (p &lt; 0.01), and shorter transport distance from trauma scene to hospital (p = 0.004), compared to those with blunt trauma. Patients with NISS &gt; 15 were found to have the same pre-hospital rescue times as those with NISS ≤ 15. There was a trend that the occurrence of gunshots was associated with increased mortality (p = 0.074). When entering age, NISS, penetrating versus blunt injury, response time, and on-scene time in a multivariate regression analysis, age (p &lt; 0.001), NISS (p &lt; 0.001), and penetrating injury (p = 0.009) remained as independent factors associated with mortality and a trend for shorter on-scene time (p = 0.093). Conclusions Pre-hospital rescue times had less impact on mortality than injury severity, age, and penetrating trauma. Even though penetrating traumas were associated with shorter on-scene time and shorter transport distance to hospital, mortality was increased in this Scandinavian urban setting.