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