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• W4247366104 abstract "We appreciate the comments and interest by Drs. Fleet and Poitras about our recent article assessing the relationship between emergency medical services (EMS) intervals and survival among trauma patients.1Newgard C.D. Schmicker R. Hedges J.R. et al.Emergency medical services time intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort.Ann Emerg Med. 2010; 55: 235-246Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar Although we did not find an association between shorter intervals and improved survival, we do not believe that the “golden hour” is dead. There is a large clinical experience base to suggest that time directly affects outcome for some trauma patients. However, as we detailed in our article, both past and current efforts to objectively demonstrate and quantify such a relationship have generally not been fruitful. If we assume that there is a time-dependent nature to maximizing health outcomes for certain trauma patients, then several potential explanations exist for our findings. First, it is possible that the other 2 time segments (time of injury to 911 contact and time from hospital arrival to definitive care) have a greater effect on outcome or that failure to account for them diminishes a potential relationship between EMS time and trauma outcomes. Second, although trauma patients are commonly considered a uniform group, such patients actually represent a very heterogeneous population. Some trauma patients have life-threatening clinical conditions that require time-dependent definitive care, whereas others have relatively minor injuries without a strict time-dependent component. Accurately identifying seriously injured patients requiring immediate trauma care early in their clinical course is an imperfect process, even when restricted to patients with physiologic compromise.2Newgard C.D. Rudser K. Hedges J.R. et al.ROC InvestigatorsA critical assessment of the out-of-hospital trauma triage guidelines for physiologic abnormality.J Trauma. 2010; 68: 452-462Crossref PubMed Scopus (40) Google Scholar, 3Newgard C.D. Rudser K. Atkins D.L. et al.ROC InvestigatorsThe availability and use of out-of-hospital physiologic information to identify high-risk injured children in a multisite, population-based cohort.Prehosp Emerg Care. 2009; 13: 420-431Crossref PubMed Scopus (18) Google Scholar Such heterogeneity in a patient population creates challenges in demonstrating the effect of time on outcome when a portion of patients have no time-dependent condition. Finally, there is strong unmeasured confounding that challenges any observational effort to demonstrate a link between time and outcome among injured patients. That is, out-of-hospital providers tend to move faster when caring for sicker, higher-acuity patients with an inherently worse prognosis (ie, those most likely to benefit from rapid care) and tend to take relatively more time among patients with less serious injuries. Because clinical severity is incompletely captured with traditional markers of injury severity, some level of confounding persists in such analyses. Including patients taken to lower-level trauma centers or nontrauma hospitals tends to worsen such confounding. The primary analysis was restricted to Level I/II patients to minimize the inherent confounding that plagues this research question; inclusion of patients transported to Level III, IV, and V centers did not qualitatively change our findings. The critical assessment of traditional dogma is not a threat to trauma systems and trauma centers, but rather functions as an essential component of continued trauma system development and enhancement. Although there is compelling information that both trauma systems and trauma centers improve outcomes among seriously injured patients,4MacKenzie E.J. Rivara F.P. Jurkovich G.J. et al.A national evaluation of the effect of trauma-center care on mortality.N Engl J Med. 2006; 354: 366-378Crossref PubMed Scopus (1745) Google Scholar, 5Mullins R.J. Veum-Stone J. Helfand M. et al.Outcome of hospitalized injured patients after institution of a trauma system in an urban area.JAMA. 1994; 271: 1919-1924Crossref PubMed Scopus (287) Google Scholar, 6Nathens A.B. Jurkovich G.J. Rivara F.P. et al.Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation.J Trauma. 2000; 48: 25-30Crossref PubMed Scopus (319) Google Scholar many questions remain about which factors actually drive these benefits. High-quality, rigorous investigation and exploration of the multitude of factors involved in trauma care offers an opportunity to evaluate which aspects of trauma systems have the greatest effect on patient outcomes and therefore represent the best targets for system enhancement. Because trauma resources are not infinite (a reality even more apparent among rural regions), efforts to both understand and refine trauma systems may offer insights to promote the most effective and efficient use of such resources. Although some may use our findings to refute any possible association between time and outcome in injury, we believe such an interpretation would be short sighted. Rather, these results offer insight into the complexities of this research question and in refining future efforts to sort out the nuances for whom, when, and how time really matters. Have We Killed the Golden Hour of Trauma?Annals of Emergency MedicineVol. 57Issue 1PreviewThe study by Newgard et al1 in the March issue of Annals proposed to set the record straight on the “golden hour” of trauma, one of the best-holding dogmas in medicine.2 They measured the association between emergency medical services (EMS) intervals and mortality among 3,656 trauma patients with substantial abnormal vital signs/mental status, transported by 146 EMS agencies to 51 trauma centers across the United States and Canada. They found no correlation. The associated capsule mentioned that “… time may be less crucial than once thought. Full-Text PDF" @default.
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• W4247366104 doi "https://doi.org/10.1016/j.annemergmed.2010.08.004" @default.
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