Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study

Abstract

Background

Whether rapid transportation can benefit patients with trauma remains controversial. We determined the association between prehospital time and outcome to explore the concept of the “golden hour” for injured patients.

Methods and findings

We conducted a retrospective cohort study of trauma patients transported from the scene to hospitals by emergency medical service (EMS) from January 1, 2016, to November 30, 2018, using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital time intervals were categorized into response time (RT), scene to hospital time (SH), and total prehospital time (TPT). The outcomes were 30-day mortality and functional status at hospital discharge. Multivariable logistic regression was used to investigate the association of prehospital time and outcomes to adjust for factors including age, sex, mechanism and type of injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and prehospital interventions. Overall, 24,365 patients from 4 countries (645 patients from Japan, 16,476 patients from Korea, 5,358 patients from Malaysia, and 1,886 patients from Taiwan) were included in the analysis. Among included patients, the median age was 45 years (lower quartile [Q1]–upper quartile [Q3]: 25–62), and 15,498 (63.6%) patients were male. Median (Q1–Q3) RT, SH, and TPT were 20 (Q1–Q3: 12–39), 21 (Q1–Q3: 16–29), and 47 (Q1–Q3: 32–60) minutes, respectively. In all, 280 patients (1.1%) died within 30 days after injury. Prehospital time intervals were not associated with 30-day mortality. The adjusted odds ratios (aORs) per 10 minutes of RT, SH, and TPT were 0.99 (95% CI 0.92–1.06, p = 0.740), 1.08 (95% CI 1.00–1.17, p = 0.065), and 1.03 (95% CI 0.98–1.09, p = 0.236), respectively. However, long prehospital time was detrimental to functional survival. The aORs of RT, SH, and TPT per 10-minute delay were 1.06 (95% CI 1.04–1.08, p < 0.001), 1.05 (95% CI 1.01–1.08, p = 0.007), and 1.06 (95% CI 1.04–1.08, p < 0.001), respectively. The key limitation of our study is the missing data inherent to the retrospective design. Another major limitation is the aggregate nature of the data from different countries and unaccounted confounders such as in-hospital management.

Conclusions

Longer prehospital time was not associated with an increased risk of 30-day mortality, but it may be associated with increased risk of poor functional outcomes in injured patients. This finding supports the concept of the “golden hour” for trauma patients during prehospital care in the countries studied.

Abstract

In a cohort study, Chi-Hsin Chen and colleagues investigate the concept of a 'golden hour' for patients requiring trauma care.

Author summary

Why was this study done?

• The concept of the “golden hour from injury to definitive care,” suggesting that critically injured patients should receive definite treatment in 60 minutes, was first proposed early in the 20th century and has been challenged because studies have shown divergence in the association between prehospital time and mortality in injured patients.

• To our knowledge, there has never been a study to adapt functional status as an outcome measurement for the impact of prehospital time in injured patients.

What did the researchers do and find?

• This 3-year, cross-national, multi-center cohort study included 24,365 patients from 4 Asian countries (Japan, Korea, Malaysia, and Taiwan).

• We found no association between prehospital time and 30-day mortality in trauma patients overall, but longer prehospital time was detrimental to functional outcome. Every 10-minute delay in total prehospital time was associated with a 6% increase in the odds of a poor functional outcome. Poor functional outcome indicates severe disability in daily life, or death.

What do these findings mean?

• Trauma patients who experienced prehospital delays were likely to have poorer functional outcomes in the countries studied.

• The prehospital delays may arise from the response time, scene control, extrication, interventions, and transportation in the prehospital setting. These findings remind the prehospital staff to optimize the prehospital time to promote favorable functional outcomes for trauma patients.

• Our analysis is susceptible to potential bias resulting from the aggregate nature of the data from different countries, unaccounted confounders such as quality of prehospital care and in-hospital management, and missing data inherent to the retrospective design.

• Policymakers from different countries and areas should make an effort to examine the influence of prehospital time and to develop suitable prehospital guidelines based on their own emergency medical service configurations.