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

Abstract

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

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

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

Fig 1. Flow diagram of patients included in our study.

EMS, emergency medical service; ISS, Injury Severity Score; MRS, Modified Rankin Scale; RTS, Revised Trauma Score; TH, Thailand; VN, Vietnam.

Fig 2. Subgroup analysis of the association between TPT and 30-day mortality in different subgroups.

*Co-variables used in the logistic regression included prehospital time intervals, age, sex, mechanism of injury, type of injury, Injury Severity Score, Revised Trauma Score, prehospital rescue airway, and prehospital intravenous or intraosseous line, except the variable of the subgroup. All variables were included in the model using a forced entry method. aOR, adjusted odds ratio; CI, confidence interval; ISS, Injury Severity Score; NA, not available; MOI, mechanism of injury; RTS, Revised Trauma Score; TBI, traumatic brain injury; TOI, type of injury; TPT, total prehospital time.

Fig 3. Subgroup analysis of the association between TPT and poor functional outcome at discharge in different subgroups.

*Co-variables used in the multivariable logistic regression included prehospital time intervals, age, sex, mechanism of injury, type of injury, Injury Severity Score, Revised Trauma Score, prehospital rescue airway, and prehospital intravenous or intraosseous line, except the variable of the subgroup. All variables were included in the model using a forced entry method. aOR, adjusted odds ratio; CI, confidence interval; ISS, Injury Severity Score; MOI, mechanism of injury; RTS, Revised Trauma Score; TBI, traumatic brain injury; TOI, type of injury; TPT, total prehospital time.

Fig 4. Restricted cubic spline regression of favorable functional outcome at discharge.

Response time (A). Scene to hospital time (B). Total prehospital time (C).