The Golden Hour

[tniuqs]

Ann Emerg Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23.

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

Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, Aufderheide TP, Minei JP, Hata JS, Gubler KD, Brown TB, Yelle JD, Bardarson B, Nichol G; Resuscitation Outcomes Consortium Investigators.

Collaborators (267)

Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA. newgardc@ohsu.edu

Comment in:

Ann Emerg Med. 2010 Mar;55(3):247-8.

Ann Emerg Med. 2010 Aug;56(2):188-200.

Abstract

STUDY OBJECTIVE: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. METHODS: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged > or =15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. RESULTS: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. CONCLUSION: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field. Copyright © 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

http://www.wikidoc.org/index.php/Golden_hour_(medicine)

Yeah I know I may be beating on a dead horse but this 'Golden Hour' is still used to market Industrial EMS, Helos, and even some First Aid Courses <sheesh>

Edited July 28, 2010 by tniuqs

[Just Plain Ruff]

http://www.wikidoc.org/index.php/Golden_hour_(medicine)

Yeah I know I may be beating on a dead horse but this 'Golden Hour' is still used to market Industrial EMS, Helos, and even some First Aid Courses <sheesh>

I kind of look at it this way.

When it's your time to go it's your time to go. If it's not then you will beat the golden hour clock.

More than likely, since it's not noted here in the study, those 800+ patients who died were more than likely injured so severely that their deaths were probably certain. Just a shot in the dark on that thought process though.

[Happiness]

Hey Squint long time no see FYI hubby canning 30 sockeye today yum yum yum. But to the subject. I think teaching people the term The Golden Hour is actually a good thing. It is always better for anyone in this field to have something in their head that makes the sense of ergency come forward in any call. My thinking of the golden hr is for city ems as for here it is out the window it is the golden 24 hrs if your lucky, but when I was first learning OFA 3 the goldn hr made me aware that there is a time limit on how long I can stay on a scene.

This is comparison to the public AED's. The studies show that yes if you attach the zappy thing within minutes the pt will have a higher rate of making it to the hospital, but in reality the mortality rate has not changed.

If one person is saved by the term Golden Hr or by the zappy thing then why the issue.

Just asking ???????????????????

[croaker260]

Ok, 1st, I am a huge fan of R Adams Cowley, the founder of the golden hour concept.

That said, the golden hour is being replaced by the tri-model model of trauma mortality.

That said, people die in one of three major time frames:

They die in

Minutes: These are the ones that EMS interventions - bleeding control, airway support,and rapid transport make the difference.

Hours: Thse are the ones that transporting to the right facility (or the wrong wone) will make the differece between life and death.

Days: The reasons people die in this phase are largely dependant on the facility they end up at, and the treatment they recieve there, but this is a multi-factoral issue.

[chbare]

There is no evidence that one person has been saved by the golden hour. At some point in our lives we learn that Santa Clause does not live in the north pole, the tooth fairy is not real and electrons do not orbit an atoms nucleus like planets. We could argue that belief in these things is not harmful; however, we need to appreciate the truth at some point for progress to occur.

Do some injuries require immediate interventions and trauma care, absolutely. Does every trauma patient spontaneously combust and die a miserable death if they do not arrive in the theatre within a magic 60 minute window?

We need to have a pragmatic and evidence based understanding of health care. Otherwise, how can we truly understand what modalities are truly helpful? I dare say the rush to deliver every trauma patient to a trauma centre has played a role in fatal ambulance accidents and perhaps has been used to place helicopters on every other block in some areas of the United States.

Take care,

chbare.

Edited July 28, 2010 by chbare

[FireMedic65]

I do not like the idea of the "Golden Hour". This causes people to rush more than they should just so he/she can get their patient to the hospital within the time frame. Don't get me wrong... quick is better, but teaching providers they need to do it all within an hour is just plain silly.

If a patient is that bad from an injury, 61mins doesn't mean they will die/get worse, 120mins doesn't mean they will get worse either, nor does 10mins mean they will be alright.

Every patient is different, every call is situational. We need to provide the best care possible in appropriate time frames, but not race to beat the clock of 60minutes.

[fiznat]

This is comparison to the public AED's. The studies show that yes if you attach the zappy thing within minutes the pt will have a higher rate of making it to the hospital, but in reality the mortality rate has not changed.

I guess it is a nitpick, but this is not true. The link between early defibrillation and neurologically-intact survival has been well documented. This is why the AHA uses early defib as one of the links in the chain of survival, and why there are AEDs everywhere these days. It definitely does make a difference (assuming the rhythm is shockable of course!).

If one person is saved by the term Golden Hr or by the zappy thing then why the issue.

Because pushing this "golden hour" doctrine diverts resources away from approaches that may actually work. One life saved by chance does not compare to the potential of many more saved through good science and good practice. We have a responsibility to our patients to provide treatments that have been properly vetted through the scientific method. The "golden hour" does not stand up to that test.

[Just Plain Ruff]

I do not like the idea of the "Golden Hour". This causes people to rush more than they should just so he/she can get their patient to the hospital within the time frame. Don't get me wrong... quick is better, but teaching providers they need to do it all within an hour is just plain silly.

If a patient is that bad from an injury, 61mins doesn't mean they will die/get worse, 120mins doesn't mean they will get worse either, nor does 10mins mean they will be alright.

Every patient is different, every call is situational. We need to provide the best care possible in appropriate time frames, but not race to beat the clock of 60minutes.

The pushing of the ems providers to get their patient to the hospital I believe does more harm than good. Here is what I mean.

EMS agency A has a required scene time of 10 mins or less. That's a short amount of time to get things done. I agree with load and go but to put immobilization, airway control and bleeding control on in less than 10 minutes, move the patient to the ambulance and get rolling in less than 10 minutes I believe is an unreal time expectation. Couple that with the discipline that sometimes goes along with missing the 10 minute rule that some services impose can and does cause providers to commit errors or omissions in patient care.

Getting tyhem to the hospital rapidly has also caused numerous EMS Accidents because the time constraints.

Why not get em there in one piece, with skills that are required performed in a controlled environment rather than rolling down the road with a diesel bolus pushing the ambulance along. Get the patient to definitive care quickly and safely.

I believe that at times, the time constraint that the golden hour puts on ems providers can cause harm to the patient due to the rushing around that seems to happen.

There are many many patients who arrive to the ER after the golden hour in private cars and I wonder if their survival and outcome is different than what the study posted found.

[FireMedic65]

The pushing of the ems providers to get their patient to the hospital I believe does more harm than good. Here is what I mean.

EMS agency A has a required scene time of 10 mins or less. That's a short amount of time to get things done. I agree with load and go but to put immobilization, airway control and bleeding control on in less than 10 minutes, move the patient to the ambulance and get rolling in less than 10 minutes I believe is an unreal time expectation. Couple that with the discipline that sometimes goes along with missing the 10 minute rule that some services impose can and does cause providers to commit errors or omissions in patient care.

Getting tyhem to the hospital rapidly has also caused numerous EMS Accidents because the time constraints.

Why not get em there in one piece, with skills that are required performed in a controlled environment rather than rolling down the road with a diesel bolus pushing the ambulance along. Get the patient to definitive care quickly and safely.

I believe that at times, the time constraint that the golden hour puts on ems providers can cause harm to the patient due to the rushing around that seems to happen.

There are many many patients who arrive to the ER after the golden hour in private cars and I wonder if their survival and outcome is different than what the study posted found.

This is why as EMS professionals we need to prove our professionalism and fight for better pre-hospital care. The more we can do pre-hosptial, the better the patient.

I agree with all else you were saying, which is kind of what my rambling was going towards. We are also expected to be enroute to the hospital within 10minutes of arriving on scene. A lot of the time, this is quite possible. I like to do my assessment on scene, vitals, IV, BGL, etc etc. It doesn't take long. But again, this is all situational and depends on the patient. Sometimes you can't sit around.

Rushing yourself through things is no good for anyone, especially the patient. The more you rush, the more you will forget to do. Taking your time TO A CERTAIN EXTENT is always how I operate. If it takes me a minute or so longer to package a patient, so be it.

There have been times when I was a student.. where we would be on scene for 30mins. The medic wanted to do everything short of a CT scan on scene. There have been other medics where if you attempted to start an IV on scene you were told to stop and go wait in the ambulance. Everything was done in the ambulance, usually when it was moving. This, I did not totally agree with in most circumstances. I was told "we have to get them to the hospital quickly before time runs out"

*shrugs*

[Happiness]

I guess it is a nitpick, but this is not true. The link between early defibrillation and neurologically-intact survival has been well documented. This is why the AHA uses early defib as one of the links in the chain of survival, and why there are AEDs everywhere these days. It definitely does make a difference (assuming the rhythm is shockable of course!).

Because pushing this "golden hour" doctrine diverts resources away from approaches that may actually work. One life saved by chance does not compare to the potential of many more saved through good science and good practice. We have a responsibility to our patients to provide treatments that have been properly vetted through the scientific method. The "golden hour" does not stand up to that test.

Ok I have to disagree first of all the golden hr where I am as I said before is the golden 24. I think the term Hour is an estimate for example if you have a stroke victim it is better for that pt to get to surgery is better than 2 hrs later, I think the term is in general and not a rule that you have to have them there or they will die. If that is what is being taught then that is wrong, but when it was explained to me it was in a way that it is the ideal situation for a critically ill person. And just so people know my time to the hospital from a scene is about 5-10 mins sometimes up to 1 hr if Im going out the highway. Oh ya my hospital has no surgery capabilities at all.

As for the AED I dont think they shouldn't be in the public as I have fundraised 4 of them for our community. They do save live's but studies do show that the mortality of those pts really dosnt change and alot of people will end up dying in the hospital or with in months of the big jammer. I got this info from a nurse who was actually apart of a group of hospitals that were doing the study, so I hope she wouldn't lie to me.

But here is an interesting once in a lifetime call I'll share with you about CPR and the AED. My partner and I were called code 3 for a code. Pt was on the phone and collapsed, his partner call the ambulance were dispatch instructer her on CPR. She said she couldnt do so ran next door and the neighbour came over and carried on. We arrived within about 10 minutes (so the guy is down for about 15min at that time) on goes the AED and 3 no shocks later off we go. In the mean time one of VFF joined in getting him to the car, he carried on with CPR and that took another 10 mins (so now he is down for 25 min)at the hospital of course drugs are involved and the Dr. Zapped him twice and holy crap 40 min later this guy has a pulse. He crashed one more time and was again zapped and again regained his pulse. He was Medivaced about 4 hrs later to the cardiac center where he passed away with his son by his side. This senerio is so unusual we were getting calls from dispatch and all the paragods asking if this really happened. The moral of this story to me is that the AED was a big part of saving his life even if was just so his family could go into that emergency room to give him a kiss, hug and say good bye. The data that was gathered through our AED is actually being analyzed for our CPR abilities and what ever else it records to see if will help in further studies.