Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort

Comparison of kinetic changes during helicopter medical evacuations: civilian versus military flights

BACKGROUND

Helicopter evacuation is crucial for providing medical care to casualties. Previous civilian studies have demonstrated that air transport can enhance survival rates compared with ground transport. However, there has been limited research on specific accelerations during helicopter flights, particularly in military flights. This study aims to analyse and compare the accelerations endured during civilian and military helicopter evacuations.

METHODS

Accelerations were recorded during evacuation flights from the site of injury to the first medical responders in civilian helicopter EC135 T1, and military Puma SA.330 and Caiman NH90 TTH helicopters. The research investigated global acceleration and compared acceleration distributions along the vertical, lateral and longitudinal axes. A specific comparative study of the take-off phases was also performed.

RESULTS

The analysis showed that vertical loads caused the most extreme accelerations for all types of helicopter but these extreme accelerations were rare and lasted for less than 1 s. Military flights show similar acceleration intensities to civilian flights, but accelerations are higher during short periods of the take-off phase.

CONCLUSIONS

The findings suggest that helicopter evacuations during military operations are as safe as civilian evacuations and highlight the importance of patient positioning in the aircraft. However, further research should investigate the haemodynamic response to accelerations experienced during actual evacuation flights.

Societal Burden of Trauma and Disparities in Trauma Care

Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Ambulance response times and 30-day mortality: a Copenhagen (Denmark) registry study

BACKGROUND AND IMPORTANCE

Ensuring prompt ambulance responses is complicated and costly. It is a general conception that short response times save lives, but the actual knowledge is limited.

OBJECTIVE

To examine the association between the response times of ambulances with lights and sirens and 30-day mortality.

DESIGN

A registry-based cohort study using data collected from 2014-2018.

SETTINGS AND PARTICIPANTS

This study included 182 895 individuals who, during 2014-2018, were dispatched 266 265 ambulances in the Capital Region of Denmark.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was 30-day mortality. Subgroup analyses were performed on out-of-hospital cardiac arrests, ambulance response priority subtypes, and caller-reported symptoms of chest pain, dyspnoea, unconsciousness, and traffic accidents. The relation between variables and 30-day mortality was examined with logistic regression.

RESULTS

Unadjusted, short response times were associated with higher 30-day mortality rates across unadjusted response time quartiles (0-6.39 min: 9%; 6.40-8.60 min: 7.5%, 8.61-11.80 min: 6.6%, >11.80 min: 5.5%). This inverse relationship was consistent across subgroups, including chest pain, dyspnoea, unconsciousness, and response priority subtypes. For traffic accidents, no significant results were found. In the case of out-of-hospital cardiac arrests, longer response times of up to 10 min correlated with increased 30-day mortality rates (0-6.39 min: 84.1%; 6.40-8.60 min: 86.7%, 8.61-11.8 min: 87.7%, >11.80 min: 85.5%). Multivariable-adjusted logistic regression analysis showed that age, sex, Charlson comorbidity score, and call-related symptoms were associated with 30-day mortality, but response time was not (OR: 1.00 (95% CI [0.99-1.00])).

CONCLUSION

Longer ambulance response times were not associated with increased mortality, except for out-of-hospital cardiac arrests.

Prehospital Transport Time and Outcomes for Pediatric Trauma: A National Study

INTRODUCTION

Historically, emergency medical services have aimed to deliver trauma patients to definitive care within the 60 min (min) "Golden Hour" to optimize survival. There is little evidence to support or refute this for pediatric trauma. The objective of this investigation was to describe national trends in prehospital transport time, in relation to the "Golden Hour," and pediatric trauma outcomes.

METHODS

Retrospective cohort study of patients (<15 y old) receiving emergency medical services trauma transport between 2017 and 2019. Transport time (less than or greater than 60 min) was the exposure variable, and analyses were adjusted for injury severity score (ISS). Continuous variables with a normal distribution were compared by t-test was and skewed variables were compared by Mann-Whitney U-test. Categorical variables were compared by Chi-Square test.

RESULTS

54,489 patients met our criteria: 49,628 blunt and 4861 penetrating. Most patients (62.2%) had transport times less than 60 min: 30,389 (61.2%) blunt and 3479 (71.6%) penetrating. The overall mortality rate was 1.6%, 1.2% for blunt and 5.5% for penetrating. For blunt trauma, mortality was higher for transport times less than 60 min (1.5%). For penetrating trauma, mortality was lower for transport times less than 60 min (0.7%). Mean ISS was greater for blunt (7.9) compared to penetrating trauma (7.1), and greater for both trauma types with transport times less than 60 min. For both trauma types, mean length of stay was significantly longer for transport times greater than 60 min, when adjusting for ISS (P < 0.001).

CONCLUSIONS

We did not find evidence that prehospital transport within the "Golden Hour" had a substantial association with survival, though it may be associated with length of stay. There are many factors contributing to trauma outcomes, so efforts should continue to expand access and pediatric readiness.

Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors

Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.

Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers

Importance

Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear.

Objective

To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children.

Design, Setting, and Participants

This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022.

Exposures

Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]).

Main Outcomes and Measures

In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality.

Results

This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives).

Conclusions and Relevance

These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.

Prehospital times and outcomes of patients transported using an ambulance trauma transport protocol: A data linkage analysis from New South Wales Australia

INTRODUCTION

Prehospital trauma systems are designed to ensure optimal survival from critical injuries by triaging and transporting such patients to the most appropriate hospital in a timely manner.

OBJECTIVES

We sought to evaluate whether prehospital time and location (metropolitan versus non-metropolitan) were associated with 30-day mortality in a cohort of patients transported by road ambulance using a trauma transport protocol.

METHODS

Data linkage analysis of routinely collected ambulance and hospital data across all public hospitals in New South Wales (NSW). The data linkage cohort included adult patients (age ≥ 16years) transported by NSW Ambulance, where a T1 Major Trauma Transport Protocol was documented by paramedic crews and transported by road to a public hospital emergency department in NSW for two years between January 2019 and December 2020. The outcomes of interest were prehospital times (response time, scene time and transport time) and 30-day mortality due to injury.

RESULTS

9012 cases were identified who were transported to an emergency department with T1 protocol indication. Median prehospital transport times were longer in non-metropolitan road transports [n = 3,071, 98 min (71-126)] compared to metropolitan transports [n = 5,941, 65 min (53-80), p < 0.001]. There was no significant difference in 30-day mortality between the two groups (1.24% vs 1.65%, p = 0.13). In the subgroup of patients with abnormal vital signs, the only predictors of mortality were increasing age, presence of severe injury (OR 24.87, 95%CI 11.02, 56.15, p < 0.001), and arrival at a non-trauma facility (OR 3.01, 95%CI 1.26, 7.20, p < 0.05). Increasing transport times were not found to increase the odds of 30-day mortality.

DISCUSSION

In the context of an inclusive trauma system and an established prehospital major trauma protocol, increasing prehospital transport times and scene location were not associated with increased mortality.

Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study

BACKGROUND

Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality.

METHODS

A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality.

RESULTS

Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality.

CONCLUSION

Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

The Multiple Functions of Melatonin: Applications in the Military Setting

The aim of this review is to provide the reader with a general overview on the rationale for the use of melatonin by military personnel. This is a technique that is being increasingly employed to manage growing psycho-physical loads. In this context, melatonin, a pleotropic and regulatory molecule, has a potential preventive and therapeutic role in maintaining the operational efficiency of military personnel. In battlefield conditions in particular, the time to treatment after an injury is often a major issue since the injured may not have immediate access to medical care. Any drug that would help to stabilize a wounded individual, especially if it can be immediately administered (e.g., per os) and has a very high safety profile over a large range of doses (as melatonin does) would be an important asset to reduce morbidity and mortality. Melatonin may also play a role in the oscillatory synchronization of the neuro-cardio-respiratory systems and, through its epigenetic action, poses the possibility of restoring the main oscillatory waves of the cardiovascular system, such as the Mayer wave and RSA (respiratory sinus arrhythmia), which, in physiological conditions, result in the oscillation of the heartbeat in synchrony with the breath. In the future, this could be a very promising field of investigation.

A Geographical Analysis of Access to Trauma Centers from US National Parks in 2018

INTRODUCTION

Millions of people visit US national parks annually to engage in recreational wilderness activities, which can occasionally result in traumatic injuries that require timely, high-level care. However, no study to date has specifically examined timely access to trauma centers from national parks. This study aimed to examine the accessibility of trauma care from national parks by calculating the travel time by ground and air from each park to its nearest trauma center. Using these calculations, the percentage of parks by census region with timely access to a trauma center was determined.

METHODS

This was a cross-sectional study analyzing travel times by ground and air transport between national parks and their closest adult advanced trauma center (ATC) in 2018. A list of parks was compiled from the National Parks Service (NPS) website, and the location of trauma centers from the 2018 National Emergency Department Inventory (NEDI)-USA database. Ground and air transport times were calculated using Google Maps and ArcGIS, with medians and interquartile ranges reported by US census region. Percentage of parks by region with timely trauma center access-defined as access within 60 minutes of travel time-were determined based on these calculated travel times.

RESULTS

In 2018, 83% of national parks had access to an adult ATC within 60 minutes of air travel, while only 26% had timely access by ground. Trauma center access varied by region, with median travel times highest in the West for both air and ground transport. At a national level, national parks were unequally distributed, with the West housing the most parks of all regions.

CONCLUSION

While most national parks had timely access to a trauma center by air travel, significant gaps in access remain for ground, the extent of which varies greatly by region. To improve the accessibility of trauma center expertise from national parks, the study highlights the potential that increased implementation of trauma telehealth in emergency departments (EDs) may have in bridging these gaps.

Accessibility calculation and equality evaluation of medical facilities for COVID-19 pandemic treatment: A case study of the Wuhan metropolitan development zone

Medical facility equality is a critical metric for determining equal access to medical care. Their spatial distribution is important for effective pandemic treatment and daily prevention in cities. This paper used the Kernel Density Two-Step Floating Catchment Area (KD2SFCA) and shortest distance methods to calculate the accessibility of designated COVID-19 Fangcang hospitals and fever clinics in the Wuhan Metropolitan Development Zone. Their equality was evaluated by the Gini coefficient and Lorentz curve. Several results were obtained: (1) The facilities’ accessibility declines radial from the central to peripheral areas. (2) Most of the demand points in the study area can reach the medical facilities for COVID-19 pandemic treatment within 60 minutes. (3) For the spatial distribution of these facilities, the equality evaluated for different time thresholds differed significantly, with long time thresholds having better equality than for short time thresholds. (4) While the distances distribution of fever clinics is balanced, the equality gap in various areas remains enormous when considering population distribution. Suggestions for optimizing the spatial distribution of pandemic treatment medical facilities in Wuhan are proposed, and which will serve as references for the planning of Wuhan’s pandemic medical facilities in the future.

Evaluating pre-hospital triage and decision-making in patients who died within 30 days post-trauma: A multi-site, multi-center, cohort study

INTRODUCTION

Evaluating pre-hospital triage and decision-making in patients who died post-trauma is crucial to decrease undertriage and improve future patients' chances of survival. A study that has adequately investigated this is currently lacking. The aim of this study was therefore to evaluate pre-hospital triage and decision-making in patients who died within 30 days post-trauma.

MATERIALS AND METHODS

A multi-site, multi-center, cohort study was conducted. Trauma patients who were transported from the scene of injury to a trauma center by ambulance and died within 30 days post-trauma, were included. The main outcome was undertriage, defined as erroneously transporting a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center.

RESULTS

Between January 2015 and December 2017, 2116 patients were included, of whom 765 (36.2%) were severely injured. A total of 103 of these patients (13.5%) were undertriaged. Undertriaged patients were often elderly with a severe head and/or thoracic injury as a result of a minor fall (< 2 m). A majority of the undertriaged patients were triaged without assistance of a specialized physician (100 [97.1%]), did not meet field triage criteria for level-I trauma care (81 [78.6%]), and could have been transported to the nearest level-I trauma center within 45 min (93 [90.3%]).

CONCLUSION

Approximately 14% of the severely injured patients who died within 30 days were undertriaged and could have benefited from treatment at a level-I trauma center (i.e., specialized trauma care). Improvement of pre-hospital triage is needed to potentially increase future patients' chances of survival.

Comparison of Jaw-Thrust Maneuver and Standard Method for Airway Management with Laryngeal Mask Airway by Paramedics during Chest Compression: A Randomized, Crossover, Manikin Study

INTRODUCTION

The first priority of the primary survey of trauma care is airway management. For patients who have a known or suspected cervical spine injury, using the jaw-thrust maneuver is critical. It was hypothesized that the jaw-thrust maneuver would ease the insertion of the laryngeal mask airway (LMA) by moving the tongue forward from the palate and posterior pharyngeal wall.

STUDY OBJECTIVES

The aim of the study was to evaluate the effect of jaw-thrust maneuver on LMA insertion times of the paramedics with or without chest compression and with or without cervical stabilization in a manikin.

METHODS

Eleven experienced paramedics inserted LMA in jaw-thrust position and standard position in chest compression without cervical stabilization scenario, chest compression with cervical stabilization scenario, cervical stabilization without chest compression scenario, and the scenario where neither cervical stabilization nor chest compression were performed. The primary outcome of the study was the comparison of LMA insertion times for each method. The secondary outcome measures were first-pass success rates and the comparison of the difficulty level of each method.

RESULTS

During the LMA placement, performing the jaw-thrust maneuver instead of the standard method did not shorten the LMA insertion times. Adding chest compression and/or cervical stabilization did not complicate the LMA insertion. All of the LMA insertion attempts during the jaw-thrust maneuver and standard method were successful.

CONCLUSION

The findings of this study suggest that LMA insertion might be attempted both during the jaw-thrust maneuver and standard position in patients with or without chest compression and with or without cervical stabilization.

Does Every Minute Really Count? Road Time as an Indicator for the Economic Value of Emergency Medical Services

OBJECTIVES

This article builds on the literature regarding the association between emergency medical service (EMS) response times and patient outcomes (death and severe injury). Three issues are addressed in this article with respect to the empirical estimation of this relationship: the endogeneity of response time (systematically quicker response for higher degrees of urgency), the nonlinearity of this relationship, and the variation between such estimations for different patient outcomes.

METHODS

Binomial and multinomial logistic regression models are used to estimate the impact of response time on the probabilities of death and severe injury using data from French Fire and Rescue Services. These models are developed with response time as an explanatory variable and then with road time (dispatch to arrival) hypothesized as representing the exogenous variation within response time. Both models are also applied to data subsets based on response time intervals.

RESULTS

The results show that road time yields a higher estimate for the impact of response time on patient outcomes than (total) response time. The impact of road time on patient outcomes is also shown to be nonlinear. These results are of both statistical significance (model coefficients are significant at the 95% confidence level) and economical significance (when taking into account the number of annual interventions performed).

CONCLUSIONS

When using heterogeneous data on EMS interventions where endogeneity is a clear issue, road time is a more reliable indicator to estimate the impact of EMS response time on patient outcomes than (total) response time.

The impact of prehospital time intervals on mortality in moderately and severely injured patients

BACKGROUND

Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality.

METHODS

All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association.

RESULTS

We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality.

CONCLUSION

A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; level III.

Indigenous communities of Peru: Level of accessibility to health facilities

Objectives

This study aimed to geospatially model the level of geographic accessibility to health facilities among Amazonian Indigenous communities in a region of Peru.

Methods

Spatial modeling of the physical accessibility of the Indigenous communities to the nearest health facility was performed through cost-distance analysis. The study area was Loreto, the region with the largest territorial area and number of Indigenous communities in Peru. The time required to reach a health facility was determined by cumulatively adding the time needed to cross the grids on the lowest cost route from the Indigenous communities' locations to the nearest health facility, by considering Amazonian geographical conditions and the main types of transport used.

Results

The median time to reach a health facility was 0.96 h (interquartile range: 0.45–2.41). Of the total communities (n = 1043), only 479 (45.93%) communities were within 1 h from the nearest health facility, and 161 (15.44%) were more than 8 h away. The Indigenous communities more than 8 h away from a health establishment were located in the border areas of the department of Loreto.

Conclusion

One in two Indigenous communities is more than 1 h from the nearest health facility.

Prehospital time for patients with acute cardiac complaints: A rural health disparity

OBJECTIVE

Delays in care for patients with acute cardiac complaints are associated with increased morbidity and mortality. The objective of this study was to quantify rural and urban differences in prehospital time intervals for patients with cardiac complaints.

METHODS

The ESO Data Collaborative dataset consisting of records from 1332 EMS agencies was queried for 9-1-1 encounters with acute cardiac problems among adults (age ≥ 18) from 1/1/2013-6/1/2018. Location was classified as rural or urban using the 2010 United States Census. The primary outcome was total prehospital time. Generalized estimating equations evaluated differences in the average times between rural and urban encounters while controlling for age, sex, race, transport mode, loaded mileage, and patient stability.

RESULTS

Among 428,054 encounters, the median age was 62 (IQR 50-75) years with 50.7% female, 75.3% white, and 10.3% rural. The median total prehospital, response, scene, and transport times were 37.0 (IQR 29.0-48.0), 6.0 (IQR 4.0-9.0), 16.0 (IQR 12.0-21.0), and 13.0 (IQR 8.0-21.0) minutes. Rural patients had an average total prehospital time that was 16.76 min (95%CI 15.15-18.38) longer than urban patients. After adjusting for covariates, average total time was 5.08 (95%CI 4.37-5.78) minutes longer for rural patients. Average response and transport time were 4.36 (95%CI 3.83-4.89) and 0.62 (95%CI 0.33-0.90) minutes longer for rural patients. Scene time was similar in rural and urban patients (0.09 min, 95%CI -0.15-0.33).

CONCLUSION

Rural patients with acute cardiac complaints experienced longer prehospital time than urban patients, even after accounting for other key variables, such as loaded mileage.

Association between the time to definitive care and trauma patient outcomes: every minute in the golden hour matters

PURPOSE

This study examined the association between lapsed time and trauma patients, suggesting that a shorter time to definitive care leads to a better outcome.

METHODS

We used the Pan-Asian Trauma Outcome Study registry to analyze a retrospective cohort of 963 trauma patients who received surgical intervention or transarterial embolization within 2 h of injury in Asian countries between January 2016 and December 2020. Exposure measurement was recorded every 30 min from injury to definitive care. The 30 day mortality rate and functional outcome were studied using the Modified Rankin Scale ratings of 0-3 vs 4-6 for favorable vs poor functional outcomes, respectively. Subgroup analyses of different injury severities and patterns were performed.

RESULTS

The mean time from injury to definitive care was 1.28 ± 0.69 h, with cases categorized into the following subgroups: < 30, 30-60, 60-90, and 90-120 min. For all patients, a longer interval was positively associated with the 30 day mortality rate (p = 0.053) and poor functional outcome (p < 0.05). Subgroup analyses showed the same association in the major trauma (n = 321, p < 0.05) and torso injury groups (n = 388, p < 0.01) with the 30 day mortality rate and in the major trauma (p < 0.01), traumatic brain injury (n = 741, p < 0.05), and torso injury (p < 0.05) groups with the poor functional outcome.

CONCLUSION

Even within 2 h, a shorter time to definitive care is positively associated with patient survival and functional outcome, especially in the subgroups of major trauma and torso injury.

Prolonged Emergency Department Stay at Referring Facilities: A Poor Trauma Performance Improvement Tool

BACKGROUND

Delays in the transfers of injured patients are perceived to increase morbidity and mortality and drive initiatives to limit the emergency department length of stay (LOS) at referring facilities (RF). RF LOS >4 hours is used for performance improvement (PI) with a large review burden with few improvement opportunities.

METHODS

A statewide trauma registry 2013-2018 was used. Descriptive and inferential statistics including logistic regression were used to evaluate nongeriatric adult patients with ED LOS <12 hours. Paired data analyses utilizing prehospital (PH) and RF variables, vital signs (VS), Glasgow Coma Score-Motor component (GCS-M), RF LOS, mortality, trauma center hospital LOS (HLOS), and intensive care unit (ICU) LOS were performed.

RESULTS

13,721 of 56,702 transfer patients were selected. Mortality fell over time in all abbreviated injury score groups. GCS-M and systolic blood pressure (SBP) were correlated with mortality in both prehospital and RF data and highest in patients with abnormal GCS-M or SBP in both settings (38.0%, 30.1%). Examination of mortality over time in the group with abnormal VS showed SBP as the only variable with increasing mortality related to RF LOS. Average HLOS and ICU LOS were longest in patients with abnormal PH and RF SBP and GCS-M.

DISCUSSION

Support for PI evaluation of RF LOS >4 hours was not identified. Increased survival over time is explained by early transfers of high mortality patients. Our data support existing efficient statewide transfers and recommend PI review of transfer patients with abnormal GCS-M and SBP in a narrower timeframe.

An assessment of the rural-urban differences in the crash response time and county-level crash fatalities in the United States

PURPOSE

This study aimed to estimate the crash response times in rural and urban counties in the United States, their association with county-level crash fatalities, and identify spatial clusters of crash fatalities across the United States.

METHODS

We analyzed data from the Fatality Analysis Reporting System (2010-2019). Data were aggregated at the county level across the contiguous United States. The selected counties (n = 3,108) were categorized as rural, micropolitan-urban, or metropolitan-urban using the 2013 rural-urban commuting area codes. The predictor variable was crash response time, and the outcome variable was county-level crash fatalities. Crash and county characteristics were used as potential confounders. We performed a spatial negative binomial regression analysis and reported the rate ratios of crash fatalities. We estimated the crude and adjusted fatality rates across all counties and identified clusters of crash fatalities across the United States.

FINDINGS

As one migrates from urban to rural areas, crash response times became significantly increasingly longer. The Emergency Medical Service (EMS) notification to scene arrival time was most predictive of crash fatalities. A minute increase in the EMS notification to scene arrival time was associated with a 1%, 2%, and 5% increased fatality rate ratio in rural, micropolitan-urban, and metropolitan-urban counties, respectively. Although crash fatalities were lower in rural counties, the crash fatality rate was 3-fold higher in rural counties compared to metropolitan-urban counties. Significant clusters of crash fatality rates were heterogeneously distributed across the United States.

CONCLUSION

Reducing crash response time may contribute to reducing crash fatalities across the United States.

Orthopaedic and trauma care in low-resource settings: the burden and its challenges

BACKGROUND AND BURDEN

Trauma with its early and late consequences disproportionately effects those from poor countries. The availability of effective orthopaedic and trauma care varies significantly across the globe.

CHALLENGES

The balancing out of quality care is required to reach the health-related UN development goal set out in 2015. A multifactorial approach addressing local, national and international aspects is key to improving the discrepancy seen between high- and low-income countries.

Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams

Background

Pre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult.

Method

The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality.

Result

The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED.

Conclusion

Pre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.

Diagnostic value of intravenous oxygen saturation compared with arterial and venous base excess to predict hemorrhagic shock in multiple trauma patients

Introduction:

In this study, with the help of peripheral vein sampling, Spvo2, and peripheral artery and vein sampling, we examined base excess (BE) in trauma patients and determined its diagnostic value for hemorrhagic shock.

Methods:

In this cross-sectional study, from 64 patients with abdominal, pelvic and chest Blunt trauma who have a score of 2 or higher trauma during treatment, blood samples were taken from peripheral vein to measure oxygen saturation and peripheral vein and artery for BE measurements and were compared in order to assess their diagnostic value in predicting the occurrence of hemorrhagic shock.

Results:

Out of 60 examined patients, 43 (71.67%) patients were diagnosed with hemorrhagic shock. The correlation for the percentage of oxygen saturation of the peripheral blood and the rate of arterial and venous BE for these r^2patients were 17.0 and 09.0, respectively, with a P value greater than 0.005. In the case of the percentage of oxygen saturation of the peripheral blood, the sensitivity and specificity were 93.03 and 11.76%, respectively. The positive and negative likelihood ratios were 1.05 and 0.59, respectively. The positive and negative predictive values were 72.73 and 40%, respectively.

Conclusion:

In general, the results of this study showed that arterial and venous excess base levels had a proper correlation, specificity and sensitivity for diagnosing and predicting hemorrhagic shock, while the percentage of oxygen saturation of peripheral blood and BE arterial and venous levels had not proper correlation to detect and predict hemorrhagic shock.

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

BACKGROUND

Although the merit of pre-hospital critical care teams such as Helicopter Emergency Medical Services (HEMS) has been universally recognized for patients with penetrating torso injuries who present with unstable physiology, the potential merit in patients initially presenting with stable physiology is largely undetermined. The ability to predict the required pre-hospital interventions patients may have important implications for HEMS tasking, especially when transport times to definitive care are prolonged.

METHODS

We performed a retrospective cohort study of patients who sustained a penetrating torso injury and were attended by the Air Ambulance Kent Surrey Sussex (AAKSS) over a 6-year period. Primary outcome was defined as the percentage of patients with penetrating torso injuries requiring HEMS-specific interventions anytime between HEMS arrival and arrival at hospital. Secondary outcomes were the association of individual patient- and injury characteristics with the requirement for HEMS interventions.

RESULTS

During the study period 363 patients met inclusion criteria. 90% of patients were male with a median age of 30 years. 99% of penetrating trauma incident occurred more than 10-min drive from a Major Trauma Centre (MTC). Presenting GCS was > 13 in 83% of patients. Significant hemodynamic- or ventilatory compromise was present in more than 25% of the patients. Traumatic cardiac arrest was present in 34 patients (9.4%), profound hypotension with SBP < 80 mmHg in 30 (8.3%) and oxygen saturations < 92% in 30 (8.3%). A total of 121 HEMS-specific interventions were performed. Although HEMS-specific interventions were associated with presenting physiology (TCA OR 1.75 [1.41-2.16], SBP < 80 mmHg (OR 1.40 [1.18-1.67] and SpO₂ < 92% (OR 1.39 [1.17-1.65], a minority of the patients presented initially with stable physiology but deteriorated on route to hospital and required HEMS interventions (n = 9, 3.3%).

CONCLUSION

HEMS teams provide potentially important contribution to the pre-hospital treatment of patients with penetrating torso injuries in rural and semi-rural areas, especially when they present with unstable physiology. A certain degree of over-triage is inevitable in these patients, as it is hard to predict which patients will deteriorate on route to hospital and will need HEMS interventions. The results of this study showing a potentially predictable geographical dispersion of penetrating trauma could inform multi-agency knife crime prevention strategy.

Prehospital time and mortality in polytrauma patients: a retrospective analysis

Background

The time from injury to treatment is considered as one of the major determinants for patient outcome after trauma. Previous studies already attempted to investigate the correlation between prehospital time and trauma patient outcome. However, the outcome for severely injured patients is not clear yet, as little data is available from prehospital systems with both Emergency Medical Services (EMS) and physician staffed Helicopter Emergency Medical Services (HEMS). Therefore, the aim was to investigate the association between prehospital time and mortality in polytrauma patients in a Dutch level I trauma center.

Methods

A retrospective study was performed using data derived from the Dutch trauma registry of the National Network for Acute Care from Amsterdam UMC location VUmc over a 2-year period. Severely injured polytrauma patients (Injury Severity Score (ISS) ≥ 16), who were treated on-scene by EMS or both EMS and HEMS and transported to our level I trauma center, were included. Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS were analyzed using logistic regression analysis. The outcome measure was in-hospital mortality.

Results

In total, 342 polytrauma patients were included in the analysis. The total mortality rate was 25.7% (n = 88). Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) respectively (p = 0.819). The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156).

Conclusion

This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality.

Prolonged Prehospital Time is a Risk Factor for Pneumonia in Trauma (the PRE-TRIP study): A Retrospective Analysis of the United States National Trauma Data Bank

BACKGROUND

Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown.

RESEARCH QUESTION

Is prolonged prehospital time an independent risk factor for pneumonia?

STUDY DESIGN AND METHODS

We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016.

RESULTS

Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (p < 0.001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (p < 0.001, 4.3% mortality without pneumonia vs. 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns.

INTERPRETATION

Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important as prolonged prehospital time may need to be considered in subsequent decision making.

CLINICAL TRIAL REGISTRATION

Not applicable.

Association of transport time with adverse outcome in paediatric trauma

Background

It is unclear how the length of prehospital transport time affects outcome in paediatric trauma. This study evaluated the association of transport time from alarm to arrival at hospital with adverse outcome in paediatric trauma patients in Sweden.

Methods

This was a retrospective study based on prospectively collected data from the Swedish trauma registry between 2012 and 2019 of children less than 18 years with major trauma (New Injury Severity Score (NISS) greater than 15). The primary outcome was 30-day mortality, and secondary outcomes were emergency interventions (e.g., chest tube or laparotomy) and low functional outcome (Glasgow Outcome Scale 2–3). Primary exposure was transport time from alarm to arrival at hospital. Co-variables in multivariable regressions were gender, age, ASA score before injury, injury intention, dominant injury type, NISS, Glasgow Coma Scale score, prehospital competence and hospital level.

Results

Among 597 patients, 30-day mortality was 9.8 per cent, emergency interventions were performed in 34.7 per cent and low functional outcome was registered in 15.9 per cent. Median transport time was 51 (i.q.r. 37–68) minutes. After adjustment for patient, injury and hospital characteristics, no association between longer transport time and 30-day mortality, frequency of emergency interventions or lower functional outcome could be found. Treatment at a university hospital was associated with a lower risk for 30-day mortality (odds ratio 0.23 (95 per cent c.i. 0.08 to 0.68), P = 0.008).

Conclusion

Longer transport time after major paediatric trauma was not associated with adverse outcome. Hence, it seems that longer transport distances should not be an obstacle against centralization of paediatric trauma care. Further studies should focus on the role of prehospital competence and other transport-associated parameters and their association with adverse outcome.

Prehospital Response Time of the Emergency Medical Service during Mass Casualty Incidents and the Effect of Triage: A Retrospective Study

OBJECTIVE

Prehospital time affects survival in trauma patients. Mass casualty incidents (MCIs) are overwhelming events where medical care exceeds available resources. This study aimed at evaluating the prehospital time during MCIs and investigating the effect of triage.

METHODS

A retrospective analysis was performed using Florida's Event Medical Services Tracking and Reporting System database. All patients involved in MCIs during 2018 were accessed, and prehospital time intervals were evaluated and compared to that of non-MCIs. The effect of MCI triage and field triage (Field Triage Criteria) on prehospital time was evaluated.

RESULTS

In 2018, it was estimated that 2236 unique MCIs occurred in Florida, with a crude incidence of 10.1-10.9/100000 people. 2180 EMS units arrived at the hospital for patient disposition with a median alarm-to-hospital time of 43.74 minutes, significantly longer than non-MCIs (39.15 min; P < 0.001). MCI triage and field triage were both associated with shorter alarm-to-hospital time (39.37 min and 37.55 min, respectively).

CONCLUSIONS

MCIs resulted in longer prehospital time intervals than non-MCIs. This finding suggests that additional efforts are needed to reduce the prehospital time for MCI patients. MCI triage and field triage were both associated with shorter alarm-to-hospital times. Widespread use may improve prehospital MCI care.

Do EMS times associate with injury severity?

In this study, emergency medical services times, along with other crash-related explanatory variables, have been used to investigate influential factors on injury severity. To overcome the complexity of emergency medical services times impact on crash outcome, the interaction effects of EMS times and injury location on the body were also investigated in a separate model. This study utilized the linked data of police-reported crash data and emergency medical services runs, including 2192 crash injuries that transferred to hospital. A random-effects ordered probit approach was implemented to identify effective factors on crash injury severity. Three models of (1) crash-related variables, (2) crash-related and emergency medical services times and (3) crash-related, emergency medical services times and interaction effects of EMS times and injury location on the body were developed. Although the outcome could not find the impact of faster emergency medical services times on injury severity in the second model, in the third model, faster response time and slower on-scene time were associated with decreasing the severity of entire-body injuries. We discuss why this may be the case.

An innovative emergency transportation scenario for mass casualty incident management: Lessons learnt from the Formosa Fun Color Dust explosion

The purpose of this research is to analyze and introduce a new emergency medical service (EMS) transportation scenario, Emergency Medical Regulation Center (EMRC), which is a temporary premise for treating moderate and minor casualties, in the 2015 Formosa Fun Color Dust Party explosion in Taiwan. In this mass casualty incident (MCI), although all emergency medical responses and care can be considered as a golden model in such an MCI, some EMS plans and strategies should be estimated impartially to understand the truth of the successful outcome.Factors like on-scene triage, apparent prehospital time (appPHT), inhospital time (IHT), and diversion rate were evaluated for the appropriateness of the EMS transportation plan in such cases. The patient diversion risk of inadequate EMS transportation to the first-arrival hospital is detected by the odds ratios (ORs). In this case, the effectiveness of the EMRC scenario is estimated by a decrease in appPHT.The average appPHTs (in minutes) of mild, moderate, and severe patients are 223.65, 198.37, and 274.55, while the IHT (in minutes) is 18384.25, 63021.14, and 83345.68, respectively. The ORs are: 0.4016 (95% Cl = 0.1032-1.5631), 0.1608 (95% Cl = 0.0743-0.3483), and 4.1343 (95% Cl = 2.3265-7.3468; P < .001), respectively. The appPHT has a 47.61% reduction by employing an EMRC model.Due to the relatively high appPHT, diversion rate, and OR value in severe patients, the EMS transportation plan is distinct from a prevalent response and develops adaptive weaknesses of MCIs in current disaster management. Application of the EMRC scenario reduces the appPHT and alleviates the surge pressure upon emergency departments in an MCI.

Methodological issues in economic evaluations of emergency transport systems in low-income and middle-income countries

A recent systematic review identified few papers on the economic evaluation of systems for emergency transport of acutely ill or injured patients. In addition, we found no articles dealing with the methodological challenges posed by such studies in low-income or middle-income countries. We therefore carried out an analysis of issues that are of particular salience to this important topic. This is an intellectual study in which we develop models, identify their limitations, suggest potential extensions to the models and discuss priorities for empirical studies to populate models. First, we develop a general model to calculate changes in survival contingent on the reduced time to treatment that an emergency transport system is designed to achieve. Second, we develop a model to estimate transfer times over an area that will be served by a proposed transfer system. Third, we discuss difficulties in obtaining parameters with which to populate the models. Fourth, we discuss costs, both direct and indirect, of an emergency transfer service. Fifth, we discuss the issue that outcomes other than survival should be considered and that the effects of a service are a weighted sum over all the conditions and severities for which the service caters. Lastly, based on the above work, we identify priorities for research. To our knowledge, this is the first study to identify and frame issues in the health economics of acute transfer systems and to develop models to calculate survival rates from basic parameters, such as time delay/survival relationships, that vary by intervention type and context.

Evaluating the impact of prehospital care on mortality following major trauma in New Zealand: a retrospective cohort study

BACKGROUND

Injury is a leading cause of death and health loss in New Zealand and internationally. The potentially fatal or severe consequences of many injuries can be reduced through an optimally structured prehospital trauma care system that can provide timely and appropriate care.

OBJECTIVE

To investigate the relationship between emergency medical services (EMS) care and survival to hospital for major trauma cases in New Zealand.

METHODS

This project is a retrospective cohort study of New Zealand major trauma cases attended by EMS providers over a 2-year period. Outcomes include survival to hospital and survival in hospital for at least 24 hours. The project has three phases: (1) identification of the cohort and assembling a bespoke longitudinal dataset linking EMS, New Zealand Major Trauma Registry and Coronial data; (2) describing the pathways and processes of care to inform an investigation of the relationships between types of EMS care and survival using propensity score modelling to adjust for case-mix differences; (3) assessment of the implications for future practice, policy and research.

DISCUSSION

The study findings will help identify opportunities to optimise the delivery of EMS care in New Zealand by informing the development or revision of existing major trauma EMS policies and guidelines, and to provide a baseline for monitoring the impact of future initiatives. Establishing an evidence-base will support a whole-of-system appraisal that could include broader complex variables relating to healthcare services throughout the continuum of trauma care.

There Is No Role for Damage Control Orthopedics Within the Golden Hour

INTRODUCTION

Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour."

MATERIALS AND METHODS

The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour.

RESULTS

Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified.

CONCLUSIONS

Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.

Comparison of pre-hospital emergency services time intervals in patients with heart attack in Arak, Iran

Background:

After cardiac arrest, the possibility of death or irreversible complications will highly increase in the absence of cardiac resuscitation within 4 to 6 minutes. Accordingly, measuring the pre-hospital services time intervals is important for better management of emergency medical services delivery. The purpose of this study then was to investigate pre-hospital time intervals for patients with heart attack in Arak city, based on locations and time variables.

Methods:

This is a retrospective descriptive cross-sectional study, which was conducted at the Arak Emergency Medical Services (EMS) during 2017-2018. Data were analyzed by SPSS version 13.

Results:

The total number of heart attack patients registered in Arak emergency medical services was 2,659 of which 51% of patients were males. Six percent of patients were under 25 and about 49 percent were between 46 and 65 years old. The average of activation, response, on-scene, transportation, recovery and total time intervals were 3:30, 7:56, 15:15, 13:34, 11:07, 12:11, and 41:25, respectively. In the city area, the shortest and longest average response time intervals were in spring and winter, respectively. In out of the city area, the shortest average response time interval was in summer and the longest one in autumn. The shortest and the longest average response time intervals in the city area were in June and March, respectively, and in out of the city area, the shortest average response time interval was in June and the longest one in April.

Conclusions:

The shorter response and delivery time interval compared to the other studies may indicate improvement in the provision of EMS. Special attention should be paid to the facilities and equipment of vehicles during cold seasons to be in the shortest possible time. Also, training and informing the staff more about the code of cardiac patients along with general public education can help improve these intervals.

Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury

PURPOSE

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes.

METHODS

Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer.

RESULTS

Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition.

CONCLUSIONS

No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

Direct admission to improve timely access to care for patients requiring transfer to a level 1 trauma center

Background

Emergency departments (EDs) at level 1 trauma centers are often overcrowded and deny ED-to-ED transfers from lower-tiered centers. Lack of access to timely level 1 care is associated with increased mortality. We evaluated the feasibility of a direct admission (DA) protocol as a method to increase timely access to a level 1 trauma center during periods of ED overcrowding.

Methods

During periods of ED overcrowding between 1 May and 31 December 2019, we admitted patients from referring EDs directly to the intensive care unit (ICU) or inpatient ward using the DA protocol. In a prospective comparative study design, we compared their outcomes to patients during the same period who were admitted through the ED when the ED was not overcrowded.

Results

During periods of ED overcrowding, transfer was requested and clinically accepted for 28 patients, of which 23 (82.1%, age 63±20.3 years, men 52.2% men) were successfully admitted via the DA protocol. Five (17.9%) were not successfully transferred due to lack of available inpatient beds. During periods when the ED was not overcrowded, 106 patients (age 62.8±23.1 years, men 52.8%) were admitted via the ED. There were no morbidity or mortality events attributed to the DA process. Time to patient arrival was 2.7 hours (95% CI 2.3 to 3.1) in the DA cohort and 1.9 hours (95% CI 1.5 to 2.4) in the ED-to-ED cohort (p=0.104). Up-triage to the ICU within 24 hours was performed in only one patient (4.3%). In-hospital mortality did not differ (3 (13%) vs. 8 (7.6%), p=0.392).

Discussion

The DA pathway is a feasible method to safely transfer patients from a referring ED to a higher-care trauma center when its ED is overcrowded.

Level of evidence

Level III, care management.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

BACKGROUND

Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

MAIN BODY

We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

CONCLUSION

The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.

The "Golden Hour" and field triage pattern for road trauma patients

INTRODUCTION

Although the term "golden hour" is a well-known concept among trauma system and emergency medical service providers, the relationship between time and trauma patient outcome and the process of prehospital care for road trauma patients in rural settings are poorly understood. As the underlying basis for triage decision-making, the estimated transport interval to trauma center is usually absent in the existing studies.

METHOD

In this study, the crash data between 2013 and 2017 were obtained from the Fatality Analysis Reporting System, and the estimated intervals were calculated by using a Geographic Information System software. By comparing the estimated intervals with actual emergency medical services records, the field triage patterns for road patients were investigated at the state and county levels.

RESULTS AND CONCLUSIONS

With the help of the interval prediction maps, the different triage patterns among counties were identified. Further, the average fatalities per 100,000 population by county from the National Highway Traffic Safety Administration were adopted to clarify the associated outcomes. The linear regression analysis results revealed that, for most states, all intervals except the notification interval had a significant correlation with the mortality. The estimated interval had a more significant relationship with the mortality than the actual transport interval. Practical applications: These findings indicated that adhering to the "golden hour" without regarding the destination may not be helpful for the survival of road trauma patients. The regression analyses and the interval maps can be used to identify patterns of inappropriate destination selection so that prospective decision-making can be improved.

The Impact of Prehospital Transport Mode on Mortality of Penetrating Trauma Patients

OBJECTIVE

The optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality.

METHODS

Using the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates.

RESULTS

A total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P < .0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P < .0001).

CONCLUSION

Helicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.

Helicopter Emergency Medical Services in Trauma Does Not Influence Mortality in South Africa

OBJECTIVE

Sub-Saharan Africa carries a large trauma burden. Helicopter emergency medical services (HEMS) have been suggested to reduce prehospital time and mortality. It is not clear whether HEMS infers a mortality benefit over ground transport in South Africa. This study aimed to determine whether HEMS improved 30-day mortality over ground emergency medical services (GEMS).

METHODS

A retrospective, case-control study was undertaken for major trauma patients transported to a private trauma center in Johannesburg. A 1-year cohort of HEMS patients was extracted and matched to GEMS patients based on mechanism, injury severity or percentage of the total body surface area burned, age, sex, and comorbidities. The odds ratio (OR) for 30-day mortality was calculated to determine the risk of death.

RESULTS

A total of 822 cases (HEMS: 272 [33%], GEMS: 550 [67%]) were reviewed. We included 410 patients in the matched cohort with equal distribution between transportation modes. The OR for mortality in the total cohort was 2.69 (95% confidence interval, 1.6-4.6; P = .003) for HEMS patients, whereas in the matched cohort the OR was 1.35 (95% confidence interval, 0.5-3.4; P = .503) for patients transported by HEMS.

CONCLUSION

In a matched cohort of major trauma patients, HEMS does not seem to improve mortality over GEMS. These results might reflect the South African HEMS dispatch model.

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

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.

Health system factors associated with post-trauma mortality at the prehospital care level in Africa: a scoping review

BACKGROUND

Africa accounts forabout 90% of the global trauma burden. Mapping evidence on health systemfactors associated with post-trauma mortality is essential in definingpre-hospital care research priorities and mitigation of the burden. The studyaimed to map and synthesize existing evidence and research gaps on healthsystem factors associated with post-trauma mortality at the pre-hospital carelevel in Africa.

METHODS

A scoping review of published studies and grey literature was conducted. The search strategy utilized electronic databases comprising of Medline, Google Scholar, Pub-Med, Hinari and Cochrane Library. Screening and extraction of eligible studies was done independently and in duplicate.

RESULTS

A total of 782 study titles and or abstracts were screened. Of these, 32 underwent full text review. Out of the 32, 17 met the inclusion criteria for final review. The majority of studies were literature reviews (24%) and retrospective studies (23%). Retrospective and qualitative studies comprised 6% of the included studies, systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%), systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%). Reported post-trauma mortality ranged from 13% in Ghana to 40% in Nigeria. Reported preventable mortality is as high as 70% in South Africa, 60% in Ghana and 40% in Nigeria. Transport mode is the most studied health system factor (reported in 76% of the papers). Only two studies (12%) included access to pre-hospital care interventions aspects, nine studies (53%) included care providers aspects and three studies (18%) included aspects of referral pathways. The types of transport mode and referral pathway are the only factors significantly associated with post-trauma mortality, though the findings were mixed. None of the included studies reported significant associations between pre-hospital care interventions, care providers and post-trauma mortality.

DISCUSSION

Although research on health system factors and its influence on post-trauma mortality at the pre-hospital care level in Africa are limited, anecdotal evidence suggests that access to pre-hospital care interventions, the level of provider skills and referral pathways are important determinants of mortality outcomes. The strength of their influence will require well designed studies that could incorporate mixed method approaches. Moreover, similar reviews incorporating other LMICs are also warranted. Key Words: Health System Factors, Emergency Medical Services [EMS], Pre-hospital Care, Post-Trauma mortality, Africa.

Road traffic injuries in a Nigerian referral trauma center: Characteristics, correlates, and outcomes

Background:

Globally, road traffic injuries (RTIs) are a leading cause of disability and trauma-related deaths. We aimed to describe the clinical and epidemiological characteristics and outcomes of RTIs in our environment to provide the evidence for effective control measures.

Methods:

This was a 1-year retrospective study of all patients with RTIs treated at the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.

Results:

Four hundred and twenty-one patients with 484 injuries were studied. The mean age of the patients was 34.4 ± 14.6 years, and the male-to-female ratio was 3.3:1. Most of the injuries occurred on intercity roads/highways (48.7%) and involved motorcycle crashes (31%). Soft-tissue injuries (27.7%) and fractures (21.9%) were the most common types of injuries. The lower extremities were the most common sites of injury. The mean injury-arrival interval was 23.2 ± 2.4 h. The injury severity score (ISS) ranged from 1 to 50, with a mean of 9.2 ± 2.9. The 1-year mortality rate was 10.7%. Traumatic brain injury, open vehicular injuries, and increased ISS were the potential risk factors for mortality.

Conclusion:

Soft-tissue injuries and fractures were the most common types of injuries. The majority of the injuries occurred on the inter-city roads and highways and involved head-on-collisions with motorcycles. The young male adults were the most commonly affected age group.

Most of the Variation in Prehospital Scene Time Is Not Related to Patient Factors, Injury Characteristics, or Geography

OBJECTIVE

The time spent on scene by emergency medical services remains highly variable. We sought to investigate how much of the prehospital scene time variation in penetrating trauma patients could be explained by prehospital factors.

METHODS

Using the 2010 to 2016 Trauma Quality and Improvement database, all adult penetrating trauma patients were included. The prehospital scene time was defined as the time from emergency medical service scene arrival to departure. Using all Trauma Quality and Improvement database variables including patient, injury (eg, Injury Severity Score), geography, and logistical (eg, transport mode) factors, multivariable linear regression models were created to predict the prehospital scene time. The prehospital scene time was treated as a continuous variable, and the degree to which the models could explain the variation in scene time was measured using the coefficient of determination (R).

RESULTS

A total of 45,560 patients were included. The median prehospital scene time was 6 minutes (interquartile range, 3-10 minutes). The R for factors in the multivariable regression model was 0.06, suggesting that 94% of the prehospital scene time variation cannot be explained by the wide range of prehospital factors.

CONCLUSION

Most of the variation in prehospital scene time cannot be explained by injury characteristics. The variation may be caused by logistical delays or system-related factors.

Prehospital Intervals and In-Hospital Trauma Mortality: A Retrospective Study from a Level I Trauma Center

BACKGROUND

The increase in mortality and total prehospital time (TPT) seen in Qatar appear to be realistic. However, existing reports on the influence of TPT on mortality in trauma patients are conflicting. This study aimed to explore the impact of prehospital time on the in-hospital outcomes.

METHODS

A retrospective analysis of data on patients transferred alive by Emergency Medical Services (EMS) and admitted to Hamad Trauma Center (HTC) of Hamad General Hospital (HGH; Doha, Qatar) from June 2017 through May 2018 was conducted. This study was centered on the National Trauma Registry database. Patients were categorized based on the trauma triage activation and prehospital intervals, and comparative analysis was performed.

RESULTS

A total of 1,455 patients were included, of which nearly one-quarter of patients required urgent and life-saving care at a trauma center (T1 activations). The overall TPT was 70 minutes and the on-scene time (OST) was 24 minutes. When compared to T2 activations, T1 patients were more likely to have been involved in road traffic injuries (RTIs); experienced head and chest injuries; presented with higher Injury Severity Score (ISS: median = 22); and had prolonged OST (27 minutes) and reduced TPT (65 minutes; P = .001). Prolonged OST was found to be associated with higher mortality in T1 patients, whereas TPT was not associated.

CONCLUSIONS

In-hospital mortality was independent of TPT but associated with longer OST in severely injured patients. The survival benefit may extend beyond the golden hour and may depend on the injury characteristics, prehospital, and in-hospital settings.

Emergency trauma care in rural and remote settings: Challenges and patient outcomes

INTRODUCTION

Trauma is a global public health concern, with higher mortality rates acknowledged in rural and remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary objective of this integrative literature review was to examine the challenges associated with providing emergency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective was to explore strategies to improve trauma patient outcomes.

METHODS

An integrative review approach was used to inform the methods of this study. A systematic search of databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other search methods included hand searching journal references.

RESULTS

2157 articles were identified for screening and 87 additional papers were located by hand searching. Of these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique challenges in the provision of emergency trauma care such as large distances, delays transferring patients to definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors, weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural and remote populations often experience higher mortality rates in comparison to urban populations although this may be different for specific mechanisms of injury or population subsets. While an increased risk of death was associated with an increase in remoteness, research also found it costs substantially less to provide care to rural patients in their rural environment than their urban counterparts. Other factors found to influence mortality rates were severity of injury and differences in characteristics between rural and urban populations. Trauma systems vary around the world and must address local issues that may be affected by distance, geography, seasonal population variations, specific population risk factors, trauma network operationalisation, referral and retrieval and involvement of hospitals and services which have no trauma designation.

CONCLUSIONS

The challenges acknowledged for rural and remote trauma patients may be lessened and mortality rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma systems that are responsive to local needs and resources. Additional research to determine which of these challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve this.