Elsevier

Injury

Volume 46, Issue 4, April 2015, Pages 602-609
Injury

The influence of prehospital time on trauma patients outcome: A systematic review

https://doi.org/10.1016/j.injury.2015.01.008Get rights and content

Abstract

Objective

Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the ‘golden hour’, the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients.

Methods

A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality.

Results

Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury.

Conclusion

Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.

Introduction

Trauma is one of the major causes of death worldwide; approximately five million people die each year as a result of traumatic injuries. In the USA alone, trauma is the leading cause of death for Americans under the age of 40 [1]. In 2011 road traffic injuries claimed nearly 3,500 lives each day worldwide [2]. Emergency medical systems (EMS) around the world are constantly evolving in order to reduce these numbers and provide better quality medical care. To do so, focus has often been on shortening prehospital times [3]. Historically, time is considered to be an essential determinant on the outcome of trauma patients. A fundamental tenet of trauma care is the ‘golden hour’, the immediate time after injury when resuscitation, stabilization and rapid transport are perceived to be most beneficial to the patient [4]. It is thought that when advanced emergency medical care is provided in this brief window of time and this time interval is kept to a minimum, mortality and morbidity of the trauma patients will be reduced [5], [6], [7], [8]. However, not all trauma literature is in concordance on this matter [9], [10]. In many emergency medical systems patients spend this extremely important time-interval in a prehospital setting, without receiving definitive care [11]. Though it seems intuitive to transport a trauma patient as fast as possible to a trauma centre, especially those with a severe haemorrhage or increasing intracranial pressure, this may have adverse effects on the outcome, as some patients may be in need of specialized care before transfer [9], [12]. There is discussion on the exact influence of the duration of time elapsed before reaching a trauma centre on patients outcome. Many of the scientific findings concerning prehospital times derive from studies done in war settings with military systems of care [13]. Whether or not this can be extrapolated to civilian trauma care, has not fully been investigated. Different ideas exist with regard to geographical factors, the mechanism of injury (MOI) and swiftness of transfer [14]. Timely transfer is thought to be a critical predictor of outcomes for patients with acute traumatic injuries in rural and developing regions. And also for the penetrating injuries where the concept of ‘scoop and run’ is often implemented. Several studies have tried to investigate the effect of prehospital time intervals on patient outcome [15], [16], [17]. So far, no study has systematically reviewed the effect of the prehospital time intervals on outcome parameters for trauma patients. The objective of this study was to systematically examine and review the influence of different time intervals in the prehospital phase on outcome measurements for trauma patients. Our aim is to provide a thorough summary of the current relevant literature.

Section snippets

Methods

This systematic review was performed according to the recommendations of the preferred reporting items for systematic reviews and meta-analysis (PRISMA statement [18]).

Results

The search yielded a total of 2,938 potentially relevant articles. After removing duplicates of references that were selected from more than one database, 2,876 references remained. We discarded 2,830 on title or abstract because they were not relevant. The full-text articles of the remaining 46 were retrieved: 26 studies were excluded from further analysis; one due to duplicity of data, 15 were discarded due to improper or no relationship between variables of interest, one was not on topic and

Limitations

It is difficult to solely address the effect of time spent in a prehospital setting on trauma patient outcome because several factors are of influence. This is reflected in the heterogeneity of the included studies. For one, patients are divided into various categories for analyses and use different types of trauma score to allocate patients. Second there are dissimilarities in included trauma mechanisms. Included subgroups are patients with penetrating injuries, blunt force trauma, TBI

Discussion

Trauma patient outcome and the relationship with prehospital time intervals are of interest to investigate. Historically emphasis has been on time and many of the changes in trauma care are based on the tenet that shorter prehospital times are better for the trauma patient, though little is empirically known on this matter. Carr et al. [37] performed a meta-analysis on prehospital care times. They provide an average duration for each time interval but do not correlate length of the interval

Conclusion

For undifferentiated trauma patients a shorter RT and TT may have a positive influence on mortality. However, it seems that a longer OST may increase odds of survival. The same trend is seen in TPT which is probably due to the relatively large share of OST in total TPT. This increased odds of survival with longer OST is presumably related to the comprehensive care that is delivered prehospitally, implying that for the future, the emphasis should not be on getting a patient to the hospital as

Conflict of interest

All authors declare there are no conflict of interest to report.

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