Longer prehospital time was not associated with mortality in major trauma. A retrospective cohort study.

(Photo Credit: Surrey Now-Leader)

Just released in the Journal of Pre-Hospital Emergency Care:

https://www.tandfonline.com/doi/abs/10.1080/10903127.2018.1551451?journalCode=ipec20&

Commentary:

As more and more research presents on the previously perceived validity of the “Golden Hour” of trauma, this research article provides opportunities to consider a balanced approach of critical interventions versus a purely “load and go” approach.  After many years of research showing reduced scene times are the defining factor, much of what is happening with advanced critical interventions with programs such as London HEMS and others, there seems to be a new trend toward advanced practitioners being the defining factor.  This is something that we need to watch closely and participate in further research.

An example of an important question; Would advanced critical care practitioners in rural environments capable of treating severely life threatening conditions in the absence of a local trauma centre be better than rapid transport alone to a local emergency department?  Recent Helicopter EMS (HEMS) studies have shown that advanced practitioners are perhaps the defining factor in those that are survivable and have not already  declare themselves unviable.

Does this support the direction for the future of paramedic practice in British Columbia?

Quote from the study offers some thoughts:

“Our finding of an association between longer on-scene times and longer LOS in those who survived at least 30-days could be attributed to these patients being those who had their immediate life threats corrected in the additional time spent on-scene and thus were less
likely to die.”

Objective: 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 1st January 2013 and 31st December 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.

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