For those with more than a decade of experience in EMS, the concept of the “Golden Hour” is likely familiar. This principle emphasizes the importance of transporting trauma patients to a Level 1 trauma center within an hour of injury to reduce mortality and morbidity. Over the years, this concept has undergone revisions, and several studies have investigated whether extended out-of-hospital times are associated with increased mortality rates.
Although these studies vary in sample size, geographic location, pre-hospital resources, and provider skillsets, the evidence suggests that out-of-hospital time, in isolation, is not a definitive predictor of patient survival. However, certain factors should still be considered. One study found that while pre-hospital time alone was not a significant determinant of outcomes, shorter out-of-hospital times were linked to improved outcomes in patients presenting with moderate shock (Okada et al., 2020).
Similarly, a study conducted in the Netherlands aimed to demonstrate a link between increased pre-hospital times and higher mortality rates. However, the findings indicated no strong correlation between out-of-hospital times and survival rates in polytrauma patients (Berkeveld et al., 2021). It is important to note that the Dutch EMS system is highly advanced, with EMS-trained nurses on ambulances and physicians staffing their Helicopter Emergency Medical Services (HEMS), as well as relatively short transport times. Despite this, their skill set is comparable to advanced pre-hospital services in the U.S., including advanced airway management, chest tube placement, blood product administration, and similar critical interventions.
While many studies focus on mortality rates, it is equally important to consider patient outcomes beyond survival. A Swedish study revealed a significant reduction in mortality rates among patients transported by HEMS compared to ground EMS, yet it also reported worse neurological outcomes in those transported by air. This raises important questions: could these outcomes be attributed to the transfer process between ground EMS and HEMS crews? Are patients’ blood pressures being adequately managed during transfer, particularly to prevent hypotension in head injury cases? Furthermore, if EMS is effectively managing the patient, is air transport always necessary? Lapidus et al. (2023) suggest that the advanced skillset of HEMS crews may explain the lower mortality rates, but they also recognize the potential for selection bias in their study, noting that HEMS is typically activated for patients with more severe injuries compared to those transported by ground. This of course, could provide insight as to why the survival numbers are greater in HEMS patients.
Each of these studies has its limitations, but they collectively emphasize the need to look beyond out-of-hospital time as the sole factor in patient survivability. Critical interventions—such as managing hypotension, early administration of blood products when indicated, appropriate use of HEMS, and consideration of the providers’ skillsets—must all be taken into account. Ultimately, our goal is not only to save lives but to ensure our patients have the best chance for a quality life after discharge.
References:
Okada, K., Matsumoto, H., Saito, N., Yagi, T., & Lee, M. (2020). Revision of ‘golden hour’ for hemodynamically unstable trauma patients: an analysis of nationwide hospital-based registry in Japan. Trauma surgery & acute care open, 5(1), e000405. https://doi.org/10.1136/tsaco-2019-
Berkeveld, E., Popal, Z., Schober, P., Zuidema, W. P., Bloemers, F. W., & Giannakopoulos, G. F. (2021). Prehospital time and mortality in polytrauma patients: a retrospective analysis. BMC emergency medicine, 21(1), 78. https://doi-org.fgul.idm.oclc.org/10.1186/s12873-021-00476-6
Lapidus, O., Rubenson Wahlin, R., & Bäckström, D. (2023). Trauma patient transport to hospital using helicopter emergency medical services or road ambulance in Sweden: a comparison of survival and prehospital time intervals. Scandinavian journal of trauma, resuscitation and emergency medicine, 31(1), 101. https://doi-org.fgul.idm.oclc.org/10.1186/s13049-023-01168-9
