Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System

Abstract

The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain.OBJECTIVE To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality. DESIGN, SETTING, AND PARTICIPANTSThis cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018. MAIN OUTCOMES AND MEASURESThe association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality.RESULTS A total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 ( 14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score Ն3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]). CONCLUSIONS AND RELEVANCEIn this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

Blunt Aortic Traumatic Injury Management: An Observational Study in 10 French Trauma Centers.

“…Time to diagnosis and time to treatment are important notions in damage control : as shown in Gauss et al study, the odds of death after adjustment increased by 4% for each 10-minute increase in prehospital time (14). Resuscitation time in the RR was 35 minutes but the "Time to diagnosis" (120 [94-171] minutes) and more importantly the "Time to treatment" (311 [240-560] minutes) were extended while diagnosis and treatment remain essential for the survival of patients with hemorrhage.…”

“…As usual in trauma population, BTAI affects mostly young males (14). Few studies focus on prehospital management of BTAI as many patients die on scene.…”

Asociación entre tiempo de atención pre hospitalaria y la mortalidad hospitalaria en víctimas de accidentes de tránsito

“…En el estudio de En Gonzalez et al (10) y Gauss et al (13) se mostró asociación con el aumento significativo y progresivo de la mortalidad con el tiempo total pre hospitalario, también se encontró que al aumento del tiempo pre hospitalario mayor a 30 minutos se asoció con un gran aumento en el riesgo de muerte en el hospital así como la demora mayor a 180 minutos. Así MILLS et al (7) La mortalidad de GAUSS et al (13) Las probabilidades de muerte aumentaron en un 9% por cada aumento de 10 minutos en el tiempo prehospitalario. BROWN et al (8) No se halló asociación entre el TAPH con la mortalidad en 30 días.…”

Effectiveness of Physician-Led Prehospital Management in Severe Trauma Patients: A Retrospective Analysis of the Japanese Nationwide Trauma Registry

“…As longer prehospital transport time has been reported to be associated with higher mortality rates, [8] it would be important to evaluate the bene t of physician-led trauma management independent of prehospital transport time for establishing optimal dispatch criteria for prehospital physician teams.…”