Emergency Medical Services Intervals and Survival in Trauma: Assessment of The "Golden Hour" in A North American Prospective Cohort

EMERGENCY MEDICAL SERVICES/ORIGINAL RESEARCH
Emergency Medical Services Intervals and Survival in Trauma:

Assessment of the “Golden Hour” in a North American
Prospective Cohort
Craig D. Newgard, MD, MPH From the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine,
Robert H. Schmicker, MS Oregon Health & Science University, Portland, OR (Newgard); the Department of Biostatistics
(Schmicker, Bardarson, Nichol), Department of Surgery (Bulger), and University of Washington Clinical
Jerris R. Hedges, MD, MS, MMM
Trial Center, University of Washington–Harborview Center for Prehospital Emergency Care (Nichol),
John P. Trickett, BScN University of Washington, Seattle, WA; the Department of Medicine, John A. Burns School of Medicine,
Daniel P. Davis, MD University of Hawaii–Manoa, Honolulu, HI (Hedges); the Department of Emergency Medicine (Trickett)
Eileen M. Bulger, MD and Department of Surgery (Yelle), University of Ottawa, Ottawa, Ontario, Canada; the Department of
Tom P. Aufderheide, MD Emergency Medicine, University of California at San Diego, San Diego, CA (Davis); the Department
of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (Aufderheide); the Department of
Joseph P. Minei, MD Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Minei); the Department of
J. Steven Hata, MD, FCCP, MSc Anesthesia, Division of Critical Care, University of Iowa, Iowa City, IA (Hata); the Legacy Emanuel
K. Dean Gubler, DO, MPH Trauma Program, Portland, OR (Gubler); and Department of Emergency Medicine, University of Alabama
Todd B. Brown, MD, MSPH at Birmingham, Birmingham, AL (Brown).
Jean-Denis Yelle, MD
Berit Bardarson, RN
Graham Nichol, MD, MPH
and the Resuscitation Outcomes
Consortium Investigators
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
ⱖ15 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 inhospital 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. [Ann Emerg Med. 2010;55:235-246.]
Please see page 236 for the Editor’s Capsule Summary of this article.
Provide feedback on this article at the journal’s Web site, www.annemergmed.com.

0196-0644/$-see front matter
Copyright © 2009 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2009.07.024
Volume , .  : March  Annals of Emergency Medicine 235

Out-of-Hospital Time and Survival Newgard et al
response interval. Meeting such expectations requires

Editor’s Capsule Summary
comprehensive emergency vehicle and personnel coverage
What is already known on this topic throughout a community and travel at high speeds in risky
The “golden hour” concept in trauma is pervasive traffic situations (eg, intersections) that occasionally result in
crashes causing injury and death to emergency vehicle occupants
despite little evidence to support it.
and others.20-22 Demonstrating the benefit of such time
What question this study addressed standards in noncardiac arrest patients is important in justifying
Is there an association between various emergency the resources and risks inherent in meeting such goals in EMS
medical services (EMS) intervals and inhospital systems. Previous studies assessing the time-outcome association
in trauma have been limited by heterogeneous patient groups,
mortality in seriously injured adults?
single EMS agencies, small sample sizes, and the exclusion of
What this study adds to our knowledge patients who died in the field.
In 3,656 injured patients with substantial
perturbations of vital signs or mental status, Goals of This Investigation
transported by 146 EMS agencies to 51 trauma In this study, we tested the association between EMS
centers across North America, no association was intervals and mortality among trauma patients known to be at
found among any EMS interval and mortality. high risk of adverse outcomes (those with field-based
physiologic abnormality) in 146 diverse EMS agencies across 10
How this might change clinical practice North American sites. Patients who died in the field were also
This study suggests that in our current out-of- examined as a subset of this population.
hospital and emergency care system time may be less
crucial than once thought. Routine lights-and-sirens MATERIALS AND METHODS
transport for trauma patients, with its inherent risks, Study Design
may not be warranted. This was a secondary analysis of an out-of-hospital,
consecutive-patient, prospective cohort registry of injured
persons with field-based physiologic abnormality.
INTRODUCTION
Background Setting
The first 60 minutes after traumatic injury has been termed These data were collected as part of the Resuscitation
the “golden hour.”1 The concept that definitive trauma care Outcomes Consortium epidemiologic out-of-hospital trauma
must be initiated within this 60-minute window has been registry (the Resuscitation Outcomes Consortium Epistry-
promulgated, taught, and practiced for more than 3 decades; the Trauma).23 The primary sample for this study was collected
belief that injury outcomes improve with a reduction in time to from December 1, 2005, through March 31, 2007. Eligible
definitive care is a basic premise of trauma systems and patients were identified from 146 EMS agencies (ground and air
emergency medical services (EMS) systems. However, there is medical) transporting to 51 Level I and II trauma hospitals in
little evidence to directly support this relationship.1 Two studies 10 sites across the United States and Canada (Birmingham, AL;
from Quebec suggested that increased total out-of-hospital (ie, Dallas, TX; Iowa; Milwaukee, WI; Pittsburgh, PA; Portland,
EMS) time was associated with increased mortality among OR; King County, WA; Ottawa, ON; Toronto, ON; and
seriously injured trauma patients,2,3 yet this finding has not Vancouver, BC). The sites vary in size, location, and EMS
been replicated in other settings.4-10 Additional studies system structure and provide care to injured persons from
suggesting a link between out-of-hospital time and outcome diverse urban, suburban, rural, and frontier regions.24 One
have been tempered by indirect comparisons,11 small samples of hundred fifty-three institutional review boards/research ethics
highly selected surgical patients,12-14 rural trauma patients with boards (127 hospital-based and 26 EMS agency-based) in both
long EMS response times,15 and mixed samples that included the United States and Canada reviewed and approved the
patients with nontraumatic cardiac arrest.16,17 Resuscitation Outcomes Consortium Epistry-Trauma project
and waived the requirement for informed consent.
Importance
To date, patients with out-of-hospital cardiac arrest remain Selection of Participants
the only field-based patient population with a consistent The primary study cohort consisted of consecutive injured
association between time (response interval) and survival.18,19 adults (aged ⱖ15 years) requiring activation of the emergency
Despite the paucity of outcome evidence supporting rapid 911 system within predefined geographic regions at each
out-of-hospital times for the broader population of patients Resuscitation Outcomes Consortium site. For the primary
activating the 911 system, EMS agencies in North America are sample, patients must have been evaluated by an EMS provider,
generally held to strict standards about intervals, particularly the had signs of physiologic abnormality at any point during out-of-
236 Annals of Emergency Medicine Volume , .  : March 

Newgard et al Out-of-Hospital Time and Survival
hospital evaluation, and required EMS transport to a hospital. enrollment and resulting sample size were based on the initial
The definition for out-of-hospital physiologic abnormality was inception of the Resuscitation Outcomes Consortium Epistry-
based on the American College of Surgeons Committee on Trauma database (December 1, 2005) through the most recent
Trauma Field Triage Decision Scheme “Step 1” criteria25 that date demonstrating complete case capture and a high level of
have been demonstrated to have high specificity for identifying outcome completion (March 31, 2007).
patients with serious injury and need for specialized trauma
resources.26-34 Injured patients with one or more of the
Methods of Measurement
following criteria were included: systolic blood pressure (SBP)
EMS intervals were calculated from dispatch records and all
less than or equal to 90 mm Hg, Glasgow Coma Scale (GCS)
available out-of-hospital patient care reports. For patients with
score less than or equal to 12, respiratory rate less than 10 or
multiple sources of time records (eg, dispatch, 2 or more patient
greater than 29 breaths/min, or advanced airway intervention
care reports from different EMS agencies), discrepancies were
(tracheal intubation, supraglottic airway, or cricothyrotomy).
resolved between data sources to produce the most accurate
“Injury” was broadly defined as any blunt, penetrating, or burn
representation of true times. Intervals were based on standard
mechanism for which the EMS provider(s) believed trauma to
EMS definitions, including activation interval (time 911 call
be the primary clinical insult.
received at dispatch to alarm activation at EMS first response
The primary analysis included patients transported directly
agency), response interval (time from alarm activation to arrival
to trauma centers to minimize the effect of hospital type
of first responding vehicle on scene), on-scene interval (time
(trauma versus nontrauma hospitals) on outcome.35 Injured
arrival of first EMS responding vehicle on scene until leaving
persons who were not transported by EMS (ie, died in the field
with or without resuscitative measures, refused transport, or the scene), and transport interval (time leaving the scene to
were not otherwise transported by EMS) were excluded from vehicle arrival at the receiving hospital).36 We defined the total
the primary analysis because certain out-of-hospital intervals EMS interval as time from 911 call received to arrival at the
(on-scene, transport, total out-of-hospital) could not be receiving hospital. This definition was used to approximate the
calculated. Children (aged ⬍15 years) were excluded because of interval from time of injury to time of definitive care and
different responses to injury, different “normal” physiologic represents a slightly longer duration than the “total out-of-
ranges compared with those of adults, and age-based variability hospital interval” defined by Spaite et al.36 Time at patient’s
in EMS procedure use (eg, tracheal intubation). Although these side and time of care transfer in the hospital were not
patients groups were excluded from the primary analysis, consistently captured by all sites and were therefore not available
information on such patients was collected during the same in this study. We considered all intervals as continuous
period and included in sensitivity analyses to better understand covariates but also evaluated categorical versions of total EMS
how the broader inclusion of such injury patients may affect time (ⱕ60 versus ⬎60 minutes) and response interval (⬍4, 4 to
study results. 8, and ⬎8) according to previously defined response intervals
Patients enrolled in a concurrent clinical trial with for cardiac arrest.18,19
embargoed outcomes (Hypertonic Resuscitation Following Fourteen additional out-of-hospital variables were considered
Traumatic Injury, ClinicalTrials.gov identifiers NCT00316017 in the analysis. Physiologic information included the initial (ie,
and NCT00316004) were also excluded from the Trauma preintervention) field values (SBP [mm Hg], GCS score,
Epistry database. respiratory rate [breaths/min], shock index [pulse rate/SBP])
and use advanced airway procedures (tracheal intubation and
Data Collection and Processing “rescue” airways [supraglottic airway or cricothyrotomy]). SBP
The process used for data collection in Resuscitation (⬍90, 150 to 179, and ⱖ180 mm Hg; reference 90 to 149 mm
Outcomes Consortium Epistry-Trauma has been described in Hg) and respiratory rate (⬍10 and ⬎29 breaths/min; reference
detail elsewhere.23 In brief, each Resuscitation Outcomes 10 to 29 breaths/min) were categorized to allow for nonlinear
Consortium site identified eligible out-of-hospital trauma associations with outcome. The “worst” physiologic values (eg,
patients from participating EMS agencies. Standardized data lowest GCS score) were also assessed to account for the portion
were collected from each agency, processed locally, entered into of patients with repeated vital sign measurements that
standardized data forms, matched to hospital outcomes, demonstrated physiologic decompensation after initial field
deidentified, and submitted to a central data coordinating center assessment. Additional variables included age (years), sex,
(Seattle, WA). Quality assurance processes included EMS mechanism of injury (motor vehicle, motorcycle, pedal cyclist,
provider data collection training, data element range and pedestrian, other transport, fall, struck by/against, stabbing,
consistency checks, and annual site visits to review randomly firearm, machinery, burn, natural/environment, other), type of
selected study records, data capture processes, and local data injury (blunt versus penetrating), trauma hospital level (I versus
quality efforts. Sites and agencies that had substantially higher II), use of intravenous or intraosseous fluids, hemorrhage
or lower monthly case capture (relative to their average), as control (ie, compression), mode of transport (ground
determined with a Poisson distribution with a 5% cutoff, were ambulance versus helicopter), EMS service level of first
sent inquiries to reduce biased sampling. The dates for responding vehicle (advanced versus basic life support), and site.

The primary outcome was inhospital mortality (whether in the injury (GCS score ⱕ8), shock (SBP ⱕ70 mm Hg or SBP 71 to
emergency department [ED] or after hospital admission). 90 mm Hg, with pulse rate ⬎108 beats/min43), advanced
We also collected and geocoded census tract location of the airway intervention, and country (United States versus Canada).
injury event (ESRI ArcMap v. 9.1, Redlands, CA) and then Two additional subgroups (aged ⱖ65 years and Revised
identified the center of these locations by weighting on census Trauma Score ⱕ2) were evaluated in post hoc analyses.
block (United States) or dissemination areas (Canada). The Regression analyses were performed using SPlus (version 6.2;
straight-line distance from the weighted center of each census tract Seattle, WA), and 2-step instrumental variable analyses were
(the “centroid”) to the receiving hospital was then calculated for done with Stata (version 9.1; StataCorp, College Station, TX).
each patient and used as an instrument in 2-step instrumental
variable analyses (described below). We validated this distance Sensitivity Analyses
measure against the “true” distance calculated from To further explore the potential for correlated data to alter
latitude/longitude coordinates for a subset of patients at 2 sites our results, we analyzed 2 additional cluster-adjusted analyses: a
(n⫽498). hierarchical linear probability model that allowed for non-
nested multilevel clustering (up to 2 EMS agencies and hospital)
Primary Data Analysis and a random-effects model with sites as clusters. To better
We used descriptive statistics to compare groups by quartile understand the relationship between time and outcome, sensitivity
of total EMS time. We then used 2 types of multivariable analyses also included injured adults transported by participating
regression models to test the association between EMS intervals EMS agencies to all types of hospitals (trauma centers and
and mortality. Multivariable logistic regression models were nontrauma centers), children (aged ⬍15 years), and patients who
used for all analyses, and 2-step instrumental variable models died in the field (activation and response intervals only).
were used for analyses in which distance fulfilled criteria as an
“instrument.” Instrumental variable analysis is an analytic RESULTS
strategy used in observational research to account for both Characteristics of Study Subjects
measured and unmeasured confounders, allowing improved Of the 7,555 patients meeting Epistry inclusion criteria and
estimation of causal effect, provided an appropriate instrument transported to a hospital, there were 4,276 adult trauma patients
is available and certain assumptions are met.37-39 The transported by 146 EMS agencies to 51 Level I or II trauma
instrumental variable analysis was proposed in our study as a centers during the 16-month period (Figure 1). After exclusion
potential analytic solution to the dilemma of unmeasured of patients with missing survival status (n⫽152), coenrollment
confounding (eg, injury severity, patient acuity) and because we in a concurrent clinical trial with embargoed outcomes
believed EMS intervals were strongly influenced by paramedic (n⫽130), and missing or erroneous out-of-hospital times,
perception of serious injury and acuity (ie, shorter times for locations, or other incomplete data (n⫽338), 3,656 adults with
sicker patients with inherently worse prognosis). Measures of complete information were retained for the primary analysis
distance have been used as instruments in previous trauma (Figure 1). Eight hundred six (22.0%) patients died after EMS
studies.40,41 Additional details about the instrumental variable transport to a hospital, including 504 (62.5% of deaths) on the
analysis are included in Appendix E1 (available online at http:// same day as EMS evaluation. Among hospitalized patients,
www.annemergmed.com). median length of stay was 2 days (interquartile range [IQR] 0 to
Study site was included in all models as a fixed-effects term 8), though this was substantially different between survivors
to account for the potential clustering of cases within sites.42 (median 3 days) and patients who died (median 0 days). When
We used an indicator of missingness to handle covariates with excluded patients (adults transported to major trauma centers;
missing data because more sophisticated methods of handling n⫽620) were compared with the study sample (n⫽3,656) for
missing values (eg, multiple imputation) present problems for important demographic, physiologic, and mechanism measures,
combining results across 2-step instrumental variable models. the excluded population was younger (median age 34 years;
The final models were generated according to a priori IQR 24 to 49 years), with slightly lower GCS scores (median 8;
understanding of known confounders. Potential interactions IQR 3 to 13), lower rate of penetrating injury (16.8%), and a
between intervals and clinical covariates were tested, and the higher rate of air medical transport (36.2%).
presence of effect modification was noted if such terms There was substantial variation between sites and countries
demonstrated statistical significance at P⬍.05. Model fit was in all intervals (Table 1). Across the 10 sites, the median (IQR)
assessed with the Hosmer-Lemeshow goodness of fit test and intervals were activation 0.98 minutes (0.27 to 1.62 minutes),
examination of diagnostic plots for change in coefficients (⌬-␤) response 4.28 minutes (3.00 to 6.30 minutes), on-scene 19.0
when individual episodes were excluded from the analysis. minutes (13.4 to 26.0 minutes), transport 10.0 minutes (6.37
Several important strata and subgroups were identified a to 15.30 minutes), and total EMS time 36.3 minutes (28.4
priori for the analysis. These groups included mode of transport to 47.0 minutes). Distribution of total EMS time is illustrated
(ground ambulance versus air medical), level of first responding in Figure 2. Descriptive characteristics of the cohort, by
EMS vehicle on scene (advanced life support versus basic life quartiles of total time, are listed in Table 2. Depressed GCS
support), injury type (blunt versus penetrating), traumatic brain score and hypotension (SBP ⱕ90 mm Hg) appeared more

Figure 1. Flow diagram of patients included in the primary analysis.

Table 1. EMS intervals among trauma patients with physiologic abnormality, by site (n⫽3,656).
Activation Interval* Response Interval* On-Scene Interval Transport Interval Total EMS Interval
Site Median IQR Median IQR Median IQR Median IQR Median IQR
Birmingham, AL 0.00 0.00-0.50 5.00 4.00-7.00 14.0 11.0-18.0 9.76 6.00-15.0 30.0 24.0-41.0
Dallas, TX 0.98 0.63-1.40 3.82 2.58-5.53 15.7 10.9-21.4 8.58 5.24-13.2 31.5 25.0-39.6
Iowa 0.86 0.02-1.53 4.00 3.00-5.55 15.4 11.9-20.0 7.98 4.93-10.2 28.1 23.3-37.2
Milwaukee, WI 0.00 0.00-1.00 3.00 3.00-4.00 22.0 16.0-27.0 12.0 9.00-15.0 38.0 32.0-45.0
Ottawa 0.60 0.37-1.00 5.44 3.88-8.19 21.2 15.9-27.5 9.67 6.45-16.0 39.3 31.2-49.1
Pittsburgh, PA 1.13 0.65-2.00 5.60 3.62-9.10 13.9 8.41-25.5 10.0 6.73-13.5 33.4 24.2-53.1
Portland, OR 0.18 0.10-0.72 4.28 3.10-5.94 16.8 12.4-23.0 13.5 9.60-18.1 36.3 29.6-45.9
Seattle/King County, WA 1.08 0.60-1.68 3.94 3.05-5.18 24.1 18.6-30.5 10.3 6.52-17.9 42.1 32.8-53.1
Toronto 1.62 1.00-2.38 4.78 3.52-7.45 19.1 14.4-25.0 9.45 5.00-15.1 37.0 29.6-48.1
Vancouver 1.70 1.12-2.68 4.99 3.16-8.18 20.3 14.8-29.3 10.1 6.24-15.5 39.0 31.1-54.5
United States 0.82 0.08-1.32 4.00 3.00-5.87 18.2 13.0-25.5 10.2 6.66-15.2 35.7 27.8-45.7
Canada 1.28 0.67-2.15 5.00 3.53-8.00 20.2 14.9-27.0 9.75 5.85-15.4 38.1 30.5-49.9
Overall 0.98 0.27-1.62 4.28 3.00-6.30 19.0 13.4-26.0 10.0 6.37-15.3 36.3 28.4-47.0
*Calculation of activation and response intervals include patients who died in the field and had nonmissing values for times (n⫽914).
common among patients with the shortest EMS times, every minute of total time 1.00; 95% confidence interval [CI]
though other physiologic measures were similar across 0.99 to 1.01) (Table 3). When the sample was assessed with
quartiles. The proportion of tracheal intubations attempted, 10-minute increments for total EMS time, there was no
median age, women, air medical transport, blunt injury, and evidence of increased mortality with increasing field times (OR
unadjusted survival all increased with increasing total EMS 0.90; 95% CI 0.80 to 1.02). Similar results were obtained when
times. total times were grouped by quartile (OR 0.95; 95% CI 0.83 to
1.08). We were also unable to demonstrate independent
Main Results associations between mortality and any other EMS interval for
In the multivariable logistic regression model, total EMS the overall sample (Table 4). When total EMS time was
time was not associated with mortality (odds ratio [OR] for dichotomized to compare patients with greater than 60 minutes

When the sample was expanded to include injured adults

transported to all types of hospitals (restricted to those with
outcomes available; n⫽5,356), there remained no association
between total EMS time and mortality (OR 1.00 per minute;
95% CI 0.99 to 1.00), or between other intervals and mortality
(data not shown). Among the 460 children transported to Level
I or II trauma centers with outcome information available, there
was no association between mortality and total EMS time or
other intervals (data not shown).
Of the 1,385 patients who died at the scene after injury,
there were 914 adults with interval data available for analysis.
Of these patients, 722 (79%) were declared dead without
attempted resuscitation, 130 (14%) had attempted resuscitation
with no documented vital signs, and 62 (7%) had attempted
Figure 2. Distribution of the total EMS times for 10 sites resuscitation with documented initial vital signs. The median
across North America (n⫽3656). (IQR) activation and response intervals for patients who died in
the field were 1.00 minute (0.43 to 1.67 minutes) and 4.92
minutes (3.27 to 7.38 minutes) for those without resuscitation;
to those with less than or equal to 60 minutes, there was no 1.03 minutes (0.58 to 1.67 minutes) and 5.00 minutes (3.62 to
association with mortality (OR 1.11; 95% CI 0.70 to 1.77). 7.69 minutes) for patients with resuscitation attempted and no
Categorization of total EMS time into quartiles did not suggest vital signs; and 1.00 minute (0.32 to 1.57 minutes) and 4.58
a threshold effect between time and mortality (quartile minutes (3.40 to 7.33 minutes) for patients with resuscitation
1⫽reference; quartile 2⫽OR 0.69, 95% CI 0.47 to 1.00; attempted and initial measurable vital signs. These intervals
quartile 3⫽OR 0.77, 95% CI 0.53 to 1.13; quartile 4⫽OR were slightly longer than the median activation interval (0.98
0.81, 95% CI 0.54 to 1.21). For categorized response interval, minutes; IQR 0.27 to 1.62 minutes) and response interval (4.28
there was no association with mortality for patients with a 4- to minutes; IQR 3.00 to 6.30 minutes) for patients transported to
8-minute interval (OR 0.95; 95% CI 0.71 to 1.25) or greater a hospital (P⬍.001). When we reevaluated the multivariable
than 8-minute interval (OR 1.22; 95% CI 0.80 to 1.85) models with both the primary sample and patients who died in
compared with patients with a response less than 4 minutes. the field after attempted resuscitation, there remained no
Two-step instrumental variable analyses were used only in statistical association between time and mortality for activation
subgroup analyses (described below) because the correlation (OR 1.00; 95% CI 0.97 to 1.04) or response (OR 1.00; 95%
between distance and time was low (F test ⬍10) for all intervals CI 0.99 to 1.04) intervals. These results persisted when all
using the primary sample. These results did not qualitatively patients who died in the field (with or without a resuscitation
change when the “worst” physiologic values were used in place attempt) were included in the models (data not shown).
of initial values (data not shown). The primary model was well
fit (Hosmer-Lemeshow goodness of fit statistic P⫽.80). There
was no evidence of effect modification between any interval and LIMITATIONS
clinical variables (all interactions P⬎.05). Previous studies have demonstrated an apparent association
Adjusted ORs for mortality among the subgroups are between increasing out-of-hospital time and decreased mortality
presented in Table 4. In multivariable logistic regression (ie, the appearance that longer times decrease mortality),7-10,16
models, there was no demonstrable association between time even after accounting for injury severity. This phenomenon is at
and mortality for any subgroup. The only subgroup that met least partly explained by EMS providers moving and driving
criteria for using instrumental variable analyses to assess total faster for patients believed to have serious injury and spending
EMS time was trauma patients transported in the United States more time on calls with patients recognized as having minor
(F statistic 46.4), and these results were not qualitatively injury (ie, less urgency to get such patients to a hospital). The
different (OR 1.00; 95% CI 0.997 to 1.001). association between increasing injury severity and decreased
on-scene and transport intervals has been previously
Sensitivity Analysis demonstrated.6,7,44 This type of confounding, which is unlikely
Using a random-effects model with sites as clusters, the lack to be fully accounted for with available variables (ie,
of association between total EMS time and mortality persisted unmeasured confounding), was the primary reason we
(OR 0.99; 95% CI 0.999 to 1.0003). In a hierarchical, non- considered instrumental variable models in addition to logistic
nested linear probability model integrating EMS agencies (up to regression. Although the instrumental variables strategy
2) and hospital as clusters, there remained no association ultimately could not be used for most analyses, the subgroup
between total EMS time and mortality (linear probability analysis that met criteria for such analysis generated results
estimate ⫺0.0004; 95% CI ⫺.001 to 0.0003). similar to those of logistic regression models.

Table 2. Characteristics of injured persons with field physiologic abnormality, by quartile of total EMS time.*
Lowest (First) Second Quartile Third Quartile Highest (Fourth)
Quartile EMS EMS Time EMS Time Quartile EMS
Characteristics Time (nⴝ917) (nⴝ913) (nⴝ927) Time (nⴝ899)
Initial physiologic measures
GCS score ⱕ12 (%) 652 (71.1) 602 (65.9) 615 (66.3) 535 (59.5)
Median GCS score (IQR) 9 (3-14) 10 (4-15) 10 (3-15) 11 (4-15)
SBP ⱕ90 mm Hg (%) 418 (45.6) 353 (38.7) 361 (38.9) 351 (39.0)
Median SBP (IQR) 100 (70.5-134) 110 (83-136) 110 (81.5-140) 110 (80-140)
RR ⬍10 or ⬎29 breaths/min (%) 162 (17.7) 167 (18.3) 146 (15.7) 167 (18.6)
Median low RR (IQR) 18 (16-24) 20 (16-24) 20 (16-24) 20 (16-24)
Pulse (beats/min)
Median low pulse (IQR) 94 (75-110) 94 (80-110) 92 (77.5-110) 92 (76-110)
Median shock index, pulse/SBP (IQR) 0.75 (0.55-1.00) 0.78 (0.62-1.00) 0.77 (0.60-1.00) 0.78 (0.57-1.05)
Tracheal intubation attempt (%) 194 (21.1) 200 (21.9) 237 (25.6) 314 (34.9)
Rescue airway (%) 22 (2.4) 14 (1.5) 14 (1.5) 15 (1.7)
Median pulse oximetry (IQR) 98 (94-99) 97 (94-99) 98 (95-100) 98 (94-99)
Demographics
Median age, y (IQR) 34 (24-49) 37 (25-50) 38 (25-53) 39 (25-54)
Male (%) 697 (76.0) 682 (74.7) 669 (72.2) 621 (69.1)
Type of injury (%)
Blunt 593 (64.7) 667 (73.1) 712 (76.8) 744 (82.8)
Penetrating 298 (32.5) 228 (25.0) 175 (18.9) 106 (11.8)
Burn 9 (1.0) 10 (1.1) 13 (1.4) 12 (1.3)
Other 7 (0.8) 6 (0.7) 16 (1.7) 12 (1.3)
Unknown 9 (1.0) 2 (0.2) 11 (1.2) 23 (2.6)
Injury mechanism (%)
Motor vehicle occupant 163 (17.8) 201 (22.0) 209 (22.5) 322 (35.8)
Motorcyclist 38 (4.1) 41 (4.5) 29 (3.1) 42 (4.6)
Pedal cyclist 23 (2.5) 29 (3.2) 17 (1.8) 16 (1.7)
Pedestrian 126 (13.7) 86 (9.4) 75 (8.1) 43 (4.8)
Other transport 3 (0.3) 6 (0.7) 10 (1.1) 20 (2.2)
Fall 160 (17.4) 212 (23.2) 267 (28.8) 231 (25.7)
Stuck by/against or crushed 65 (7.1) 80 (8.8) 91 (9.8) 82 (9.1)
Cut/pierce stab 102 (11.1) 78 (8.5) 72 (7.8) 38 (4.2)
Fire/burn 10 (1.1) 12 (1.3) 10 (1.1) 10 (1.1)
Machinery 5 (0.5) 2 (0.2) 4 (0.4) 5 (0.6)
Firearm gunshot 183 (20.0) 139 (15.2) 98 (10.6) 57 (6.3)
Natural/environment 1 (0.1) 0 0 0
Other 17 (1.9) 23 (2.5) 29 (3.1) 23 (2.6)
Unknown 19 (2.1) 4 (0.4) 16 (1.7) 9 (1.0)
Scene information
Time of day
Morning (%) 100 (10.9) 112 (12.3) 143 (15.4) 144 (16.0)
Day (%) 194 (21.1) 219 (24.0) 229 (24.7) 244 (27.1)
Evening (%) 302 (32.9) 286 (31.3) 269 (29.0) 267 (29.7)
Night (%) 321 (35.0) 296 (32.4) 286 (30.9) 244 (27.1)
Weekend (%) 324 (35.3) 315 (34.5) 336 (36.2) 313 (34.8)
Air medical transport 2 (0.2) 7 (0.8) 20 (2.2) 133 (14.8)
Hospitals receiving patients 40 43 47 44
Outcomes
Mortality (%) 268 (29.2) 189 (20.7) 181 (19.5) 168 (18.7)
Median hospital length of stay (days) 1 (0-8) 2 (0-8) 2 (0-8) 3 (0-11)
RR, Respiratory rate.
*Values were calculated according to available (ie, nonmissing) data. Rescue airways included supraglottic airway (eg, esophageal-tracheal twin-lumen airway device
[Combitube; Kendall-Sheridan Catheter Corp, Argyle, NY]) or cricothyrotomy.
Detailed hospital-based information, including measures of confounding by injury severity, though it is possible that these
injury severity (eg, Injury Severity Score), was not available in measures did not fully account for such relationships. We also
the Resuscitation Outcomes Consortium Epistry-Trauma did not have longer term (eg, 30-day survival) or functional
database. We used field-based information to adjust for outcomes for these patients, either of which may have altered

Table 3. Multivariable logistic regression model evaluating the fully accounting for such potentially correlated data. However,
association between total EMS time and mortality (n⫽3,656).* different model specification (ie, hierarchical) to account for
Covariates OR 95% CI non-nested multilevel clustering (ie, EMS agency, hospital) and
Total EMS time (by minute) 1.00 (0.99-1.01)
using random-effects models did not qualitatively change our
Ln (age) 4.63 (3.34-6.42) study results. It is also possible that addressing the study
Sex 0.87 (0.65-1.16) question using sites with mature EMS systems and relatively
Air transport 0.71 (0.34-1.48) short EMS intervals could have suppressed a demonstrable
GCS score obtained 5.42 (3.17-9.26) association between time and outcome. That is, most patients
Total GCS score (by increasing score) 0.81 (0.78-0.84)
SBP obtained 0.10 (0.04-0.23)
had a total EMS time well below 60 minutes, which may have
SBP ⬍90 mm Hg 1.62 (1.10-2.38) precluded the ability to fully test the “golden hour” premise
180⬎SBPⱖ150 mm Hg 1.06 (0.71-1.58) based on a 60-minute cut point. A nonlinear relationship
SBP ⱖ180 mm Hg 1.57 (0.93-2.65) between time and outcome could also exist, though categorical
150⬎SBPⱖ90 mm Hg Reference terms for the total EMS interval and response interval did not
Respiratory rate obtained 0.39 (0.21-0.75)
Respiratory rate ⬍10 breaths/min 3.87 (2.45-6.12)
suggest such a relationship.
Respiratory rate ⬎29 breaths/min 1.42 (0.93-2.19) The duration of time from EMS dispatch through delivery to
29ⱖRRⱖ10 Reference the receiving hospital represents only a portion of the time from
Shock index ⱖ1.0 1.32 (0.93-1.88) actual injury event to definitive care. We did not know the time
Shock index ⬍1.0 Reference of injury and were therefore unable to measure the interval from
Firearm or stabbing 1.06 (0.57-1.96)
Burn 2.02 (1.37-2.99)
injury onset to hospital arrival, which may represent a critical
Struck by/against crushed or fall 0.79 (0.22-2.82) window for a small portion of patients (eg, those who die in the
Other injury mechanism 0.93 (0.67-1.28) field). Our definition for total EMS time and the “golden hour”
Motor vehicle related Reference in this study was based on the assumption that the time between
Intravenous or intraosseous line placed 1.03 (0.69-1.56) injury onset and 911 notification was short, though this may
Hemorrhage control 0.72 (0.50-1.03)
Tracheal intubation attempt 3.76 (2.65-5.34)
not have been the case with all patients (eg, unwitnessed injury
Rescue airway 2.60 (1.10-6.15) events, rural areas, lack of immediate telephone access, or call
Hospital level 1.13 (0.72-1.77) coverage). Time to hospital arrival may also be different from
*Site was included in the model as a fixed-effects term to account for clustering.
the time to definitive care (eg, for patients requiring operative
intervention or other important hospital-based interventions),
which may also have affected the ability to demonstrate an
association between time and outcome.
the results. In addition, the exclusion of patients enrolled in the Finally, the use of instrumental variable analysis is predicated
concurrent clinical trial and those with missing data could have on having an available instrument that fulfills all the required
introduced bias to the results. criteria and assumptions. Unfortunately, after geocoding of all
There was substantial variability in intervals between sites and injury census tracts to generate the distance measure in this
heterogeneity in our patient population. Such differences likely sample, distance did not ultimately have a strong correlation
reflect geographic variation (eg, rural land mass), variability in EMS with EMS intervals. There was only one subgroup that
agencies, EMS system differences, population variation in injury met our predefined criteria to use distance as an instrument
mechanisms (eg, penetrating trauma), and response to injury, plus (F test ⬎10), and this analysis produced similar results to those
other factors. A large meta-analysis similarly demonstrated time from logistic regression models. Despite the fact that we could
differences among trauma patients cared for by urban/suburban use instrumental variable methods in only a small portion of the
versus rural ground ambulance crews, especially for activation, analysis, we believe these results support our overall findings of
response, and transport intervals.45 Although the inclusion criteria no demonstrable association between time and outcome.
were designed to reduce heterogeneity and isolate a field-identified
high-risk trauma population, some variability between patients and DISCUSSION
sites was unavoidable. This variability may have further reduced our In this study, we were unable to support the contention that
ability to demonstrate an association between time and outcome, shorter out-of-hospital times (as measured from receipt of 911 call
though we believe inclusion of such a broad and heterogeneous to hospital arrival) improve survival among injured adults with
group of sites increased the generalizability of our findings. field-based physiologic abnormality. This finding persisted across
In addition to variation in intervals, there was also likely many subgroups, including level of first responding EMS provider,
variation in field care, hospital care, and injury characteristics mode of transport, country, age, injury type, and more severe
between sites, EMS agencies, and hospitals. We attempted to physiologic derangement. Our findings are consistent with those of
account for this possibility by using fixed-effects models, with previous studies that similarly have failed to demonstrate a
sites as clusters. There was likely clustering present on many relationship between out-of-hospital time and outcome using
levels (eg, EMS agencies, hospitals, providers), with overlap different patient populations, trauma and EMS systems, regions,
between clusters (non-nested), which produced challenges in data sources, and confounders.4-10 However, we believe our

Table 4. Adjusted ORs for mortality, using EMS intervals (in minutes) among injury subgroups.*
Activation Response On-Scene
Subgroup/Strata n Total EMS Interval Interval Interval Interval Transport Interval
Ground 3,498 1.00 (0.99-1.01) 1.00 (0.95-1.05) 1.00 (0.96-1.04) 1.00 (0.98-1.01) 1.00 (0.99-1.01)
Air 158 0.97 (0.91-1.02) 0.67 (0.25-1.79) 1.00 (0.87-1.16) 1.03 (0.97-1.09) 0.93 (0.86-1.02)
Blunt 2,716 1.00 (0.99-1.005) 1.00 (0.95-1.05) 1.01 (0.97-1.06) 0.99 (0.98-1.01) 0.99 (0.98-1.01)
Penetrating 807 1.01 (0.99-1.04) 1.01 (0.73-1.39) 1.03 (0.94-1.13) 1.02 (0.99-1.05) 1.01 (0.96-1.06)
TBI (GCS score ⱕ8) 1,145 0.99 (0.98-1.003) 0.92 (0.82-1.03) 0.98 (0.93-1.04) 0.99 (0.98-1.01) 0.99 (0.97-1.01)
Shock (SBP ⱕ70, or SBP 71-90 1,483 0.99 (0.98-1.01) 0.86 (0.68-1.10) 1.02 (0.95-1.09) 1.00 (0.98-1.03) 0.97 (0.94-1.001)
with pulse rate ⱖ108 beats/min)
Advanced airway management 945 0.99 (0.98-1.01) 1.05 (0.95-1.16) 0.97 (0.89-1.05) 1.00 (0.98-1.02) 0.98 (0.96-1.01)
Revised Trauma Score ⱕ2 79 1.01 (0.94-1.09) 1.79 (0.49-6.50) 1.32 (0.51-3.44) 1.00 (0.93-1.08) 1.09 (0.87-1.36)
BLS first arriving 1,803 1.01 (0.99-1.02) 1.03 (0.97-1.10) 0.99 (0.94-1.05) 1.01 (0.99-1.03) 1.00 (0.997-1.003)
ALS first arriving 1,853 0.99 (0.98-1.002) 0.76 (0.60-0.96) 1.01 (0.96-1.06) 0.99 (0.97-1.01) 0.99 (0.97-1.001)
Elders (ⱖ65 y) 472 1.00 (0.99-1.02) 1.02 (0.96-1.07) 0.98 (0.89-1.07) 1.00 (0.97-1.03) 1.03 (0.996-1.06)
†
United States 2,610 0.99 (0.98-1.004) 1.04 (0.97-1.11) 1.04 (0.98-1.09) 0.99 (0.97-1.01) 0.99 (0.97-1.01)
Canada 1,046 1.00 (0.99-1.01) 0.94 (0.85-1.04) 0.97 (0.91-1.03) 1.00 (0.98-1.02) 1.00 (0.98-1.02)
Overall 3,656 1.00 (0.99-1.01) 1.00 (0.95-1.05) 1.00 (0.97-1.04) 1.00 (0.99-1.01) 1.00 (0.98-1.01)
TBI, Traumatic brain injury; BLS, basic life support; ALS, advanced life support.
*In addition to interval, multivariable logistic regression models included the following covariates: age, sex, mode of transport, site, GCS score, SBP, respiratory rate,
shock index, mechanism of injury, field intravenous or intraosseous fluid administration, tracheal intubation attempt, use of a rescue airway, field hemorrhage control,
and hospital level. For each time interval point estimate, 95% confidence intervals are listed in parentheses.
†
Results for 2-step instrumental variable analyses for US trauma patients: OR 1.00 (95% CI 0.997 to 1.001).
findings are unique because of the field-based inclusion criteria for a survival benefit of trauma systems and trauma centers,2,35,46-49
recognized high-risk subset of injured patients, the sampling design the benefit of advanced out-of-hospital trauma care (eg,
of Epistry (population-based data from a large number of EMS advanced airway intervention and intravenous fluid
agencies and sites across North America), sensitivity analyses that resuscitation) remains unclear. Further, there is a growing body
included deaths in the field and non–trauma center patients, and of literature questioning the benefit of out-of-hospital advanced
rigorous data collection for EMS times that accounted for multiple life support practices in trauma patients.4,50-54 Although some
EMS agencies caring for the same patient. seriously injured individuals may require time-dependent EMS
It is possible that other factors, such as unmeasured interventions to survive (eg, airway obstruction, respiratory
confounders, selection bias, statistical approach, inclusion arrest, external hemorrhage at a compressible site), faster
criteria, intervals assessed, or heterogeneity in the sample application of such interventions may not have a measureable
(variance), precluded our ability to show such an association. effect on outcomes for most trauma patients. It is also plausible
Although it is likely that minutes do affect outcome for certain that the “golden hour” is primarily dependent on the timeliness
severely injured individuals, demonstrating this relationship of hospital-based interventions (ie, initiation of definitive care
across a field-defined population of injured persons using EMS after arrival at an ED), rather than out-of-hospital care.
intervals has generally produced inconclusive results. The 2 Although the relationship between hospital time and outcome
previous studies from Quebec suggesting an association between among seriously injured patients also remains unproven, such a
total out-of-hospital time and mortality were conducted with possibility would lend credence to the “golden hour” concept
retrospectively defined samples of seriously injured patients2,3 and be consistent with the previously demonstrated hospital-
and have not been replicated in other settings. Although a based effect on survival.35
cornerstone of trauma systems, the “golden hour” premise has The relationship between duration of on-scene time and
proven challenging to consistently demonstrate across larger outcomes in trauma also remains unclear. In this study, we were
samples of trauma patients and specific EMS intervals. One unable to demonstrate a significant relationship between time
must also consider the possibility that assessing the influence of on-scene and mortality. Previous studies have suggested that
EMS time on outcome is not feasible through an observational on-scene time is affected by injury severity, plus the number and
study design because of inherent forms of bias and unmeasured type of EMS interventions.44,55,56 As with response intervals,
confounding. Because more rigorous study designs (ie, many urban EMS systems are held to specific standards for the
randomized controlled trials or quasi-experimental designs) are acceptable duration of on-scene care. As the scope of practice
generally not practical, feasible, or ethical for addressing this among EMS providers increases (eg, rapid sequence tracheal
study question, adequately testing the hypothesis that shorter intubation, advanced airway management, use of additional
intervals improve outcomes may not be possible. medications), such standards may help to contain the
The only condition in which rapid EMS response has been opportunity for very long on-scene times. However, our results
shown to consistently improve survival is nontraumatic cardiac do not suggest an important association between shorter scene
arrest.18,19 Although several studies have demonstrated the times and improved survival.

Similarly, there has been little information to evaluate the that might create any potential conflict of interest. See the
potential effect of transport times on outcomes in trauma. Manuscript Submission Agreement in this issue for examples
Patients perceived by EMS providers to have serious injury are of specific conflicts covered by this statement. The
frequently transported to the hospital by “lights and siren” to Resuscitation Outcome Consortium was supported by a series
of cooperative agreements to 10 regional clinical centers and
facilitate rapid arrival at a trauma center. The demonstrated
1 data coordinating center (5U01 HL077863, HL077881,
survival benefit of treating seriously injured patients in trauma HL077871, HL077872, HL077866, HL077908, HL077867,
centers2,35,46-49 suggests that time lost bypassing nontrauma HL077885, HL077877, HL077873) from the National Heart,
hospitals is recouped by the benefits of specialized care provided Lung, and Blood Institute, in partnership with the National
for injured persons at major trauma centers. One previous study Institute of Neurological Disorders and Stroke, US Army
found that although transport times to trauma centers were Medical Research and Material Command, the Canadian
higher for patients bypassing other local facilities, longer Institutes of Health Research-Institute of Circulatory and
transport times were not associated with adverse outcomes.57 Respiratory Health, Defence Research and Development
Our findings support this conclusion and further substantiate Canada, the Heart and Stroke Foundation of Canada, and the
the practice of transporting patients presumed to have serious American Heart Association.
injury to trauma centers, despite longer transport times. Publication dates: Received for publication March 13, 2009.
Although the association between out-of-hospital time and Revision received June 19, 2009. Accepted for publication
outcome remains unsubstantiated beyond persons in cardiac July 22, 2009. Available online September 22, 2009.
arrest, there is a public expectation of rapid EMS response and Presented as an abstract at the Society for Academic
care after activation of the 911 system. In the setting of a Emergency Medicine Annual Meeting, May 2008,
perceived “emergency,” the public may not necessarily value Washington, DC.
whether faster EMS time and expeditious care have been shown
Reprints not available from the authors.
to save lives for the majority of clinical conditions. However,
meeting these expectations costs money (eg, establishment of Address for correspondence: Craig D. Newgard, MD, MPH,
fire houses and positioning of EMS crews to achieve predefined Department of Emergency Medicine, Center for Policy and
response intervals), can place EMS providers, patients, and the Research in Emergency Medicine, Oregon Health & Science
University, 3181 SW Sam Jackson Park Road, Mail Code
nearby public at risk,20-22 and is a common reason (ie,
CR-114, Portland, OR 97239-3098; 503-494-1668,
emergency vehicle crashes) for tort claims against EMS
fax 503-494-4640; E-mail newgardc@ohsu.edu.
agencies.58 In an increasingly costly and competitive health care
environment, these factors must be contemplated when seeking
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54. Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: 57. Sloan EP, Callahan EP, Duda J, et al. The effect of urban trauma
where are we? Ann Emerg Med. 2006;47:532-541. system hospital bypass on prehospital transport times and level
55. Birk HO, Henriksen LO. Prehospital interventions: on-scene time 1 trauma patient survival. Ann Emerg Med. 1989;18:1146-1150.
and ambulance technicians’ experience. Prehosp Disaster Med. 58. Wang HE, Faibanks RJ, Shah MN, et al. Tort claims and adverse events
2002;17:167-169. in emergency medical services. Ann Emerg Med. 2008;52:256-262.
American Board of Emergency Medicine

2010 Subspecialty Certification Examinations
Hospice and Palliative Medicine

The American Board of Internal Medicine (ABIM) will administer the certifying examination in Hospice and Palliative Medicine on
November 16, 2010. ABEM diplomates may apply through one of three pathways – ACGME-accredited fellowship training in
Hospice and Palliative Medicine, practice, or current certification by the American Board of Hospice and Palliative Medicine, by
submitting their applications to ABEM between January 15 and April 30, 2010.
Medical Toxicology
ABEM will administer the certifying examination in Medical Toxicology on November 1, 2010. ABEM diplomates and diplomates
of ABMS boards other than the American Board of Pediatrics (ABP) and the American Board of Preventive Medicine (ABPM) may
apply to ABEM if they have completed an ACGME-accredited two-year fellowship program in Medical Toxicology. ABEM will accept
applications between January 15 and April 15, 2010. Diplomates of ABP or ABPM must submit their applications through ABP
and ABPM, respectively.
Sports Medicine
The American Board of Family Medicine (ABFM) will administer the certifying examination in Sports Medicine July
12 – 15, 17, and 19 – 24, 2010. ABFM will also administer the examination to specifically designated candidates December 1
through 4, 2010. Contact ABEM for additional information on the December examination. ABEM diplomates who have completed
ACGME accredited fellowship training in Sports Medicine must submit their Sports Medicine applications to ABEM between
February 1 and June 1, 2010, if they wish to take the July examination.
Undersea and Hyperbaric Medicine

The American Board of Preventive Medicine (ABPM) will administer the certifying examination in Undersea and Hyperbaric
Medicine October 4 through 15, 2010. ABEM diplomates may apply through one of three pathways – ACGME-accredited
fellowship training in Undersea and Hyperbaric Medicine, unaccredited fellowship training, and practice-plus-training, by
submitting their applications to ABEM between March 1 and June 30, 2010. Application through unaccredited fellowship training
and the practice-plus-training pathways will be discontinued as of June 30, 2010.
To request a certification application for one of these subspecialties, please write or call the ABEM office. Eligibility criteria for
ABEM diplomates are available on the ABEM website, www.abem.org.
AMERICAN BOARD OF EMERGENCY MEDICINE

3000 Coolidge Road
East Lansing, MI 48823-6319
Telephone: 517.332.4800
Fax: 517.332.4853

APPENDIX E1. Instrumental variables analysis. Core Investigators: Todd B. Brown, MD, MSPH, Thomas
Instrumental variable analysis is an analytic strategy used in obser- Terndrup, MD
vational research to account for both measured and unmeasured con- Coordinators: Shannon W. Stephens, EMT-P, Carolyn R. Wil-
founders, allowing improved estimation of causal effect, provided an liams, BSN, BSME
appropriate instrument is available and certain assumptions are EMS Investigators/Collaborators: Joe E. Acker, EMT-P, MPH,
met.37-39 Instrumental variable analysis was proposed in our study as Michael L. Minor, EMT-P
a potential analytic solution to the dilemma of unmeasured con- Hospital Investigators/Collaborators: Paul A. MacLennan,
founding (eg, injury severity, patient acuity, and the phenomenon of PhD, Patrick R. Pritchard, MD, Sandra Caldwell, MA, Katherine
shorter times for sicker patients with inherently worse prognosis) that R. Lai, BS
may not have been fully accounted for in measured predictor vari- Participating EMS Agencies:
ables. Martens et al37 observed that through certain assumptions, the Alabama LifeSaver, Bessemer Fire and Rescue, Birmingham Fire
causal effect of the exposure (in this case, time) on the outcome can be and Rescue, Center Point Fire District, Chelsea Fire and Rescue,
captured through the relationship between the exposure and the in- American Medical Response, Homewood Fire Dept., Pelham Fire
strumental variable. Specifically, McClellan et al38 observed that it is Dept., Rocky Ridge Fire Dept., Regional Paramedic Services,
possible to mimic randomization of patients to the likelihood of Trussville Fire Dept., Vestavia Hills Fire and Rescue
receiving a certain treatment according to the association between
treatment and the instrumental variable. This process eliminates un- Dallas Center for Resuscitation Research, University of Texas
measured confounders and allows for the estimation of causal effect Southwestern Medical Center, Dallas, TX: Ahamed H. Idris,
in terms of the likelihood. A Hausman test is also generally used to MD, Principal Investigator
determine whether a single equation model is sufficient versus use of Core Investigators: Fernando Benitez, MD, Raymond Fowler,
a 2-step instrumental variable analysis to remove bias associated with MD, Dorothy Lemecha, MD, Joseph Minei, MD, Paul Pepe, MD,
unobserved confounders. Michael Ramsay, MD, Robert Simonson, MD, Jane Wigginton,
In essence, 2 relevant equations are estimated: MD
Y⫽␣⫹␤T⫹␪X⫹E (1) Coordinators: Dixie Climer, RN, Melinda Moffat, RN, Kate
T⫽␥⫹␦Z⫹␪X⫹F (2) Newman, RN, Pamela Owens, Andrea Bennett, BS
where Y is the outcome of interest, T is the predictor of interest EMS Investigators/Collaborators: Richard Black, EMT-P, Debra
(eg, time), X represents other confounders, Z is the instrumental Cason, RN, Billy Craft, EMT-P, Lucy Detamble, RN, Ryan Dykes,
variable, and E and F are error terms. The key assumptions in EMT-P, Tony Harvey, EMT-P, Suzanne Hewitt, RN, Marshal
instrumental variable analyses are (1) Z and T are highly corre- Isaacs, MD, Joe Kay, EMT-P, Tami Kayea, EMT-P, Richard La-
lated such that T can be predicted from Z; (2) there is no con- Chance, EMT-P, Thomas Lehman, Paul Mayer, MD, Jeffrey
founding of the Z and T association; and (3) Z and Y are uncor- Metzger, MD, Danny Miller, EMT-P, Kenneth Navarro, EMT-P,
related (except through Z’s influence on T). Steven Parker, EMT-P, Karen Pickard, RN, Warren Porter, EMT-P,
We proposed using distance as an instrumental variable because of TJ Starling, EMT-P, Tommy Tine, EMT-P, Chris Vinson, EMT-P
its perceived correlation with time, lack of correlation with survival Hospital Investigators/Collaborators: David Abebefe, MD,
(except through time), and demonstrated success in previous trauma Steven Arze, MD, Sean Black, MD, Matthew Bush, MD, Michael
research with instrumental variable analyses.40,41 In this situation, if Forman, MD, Jeffery Goodloe, MD, Ralph Kelly, DO, Gregory
we assume distance to be Z and time T, we then use the instrumental Lachar, MD, Alicia Mangram, MD, Marc Morales, MD, Edward
variable model to estimate the likelihood of different intervals accord- Thornton, MD, Robert Wiebe, MD
ing to distance; this likelihood is then used to estimate the causal effect Participating EMS Agencies:
of time on outcome. Because a weak instrument can introduce bias to Carrollton Fire Dept., Dallas Fire and Rescue, DeSoto Fire Dept.,
an analysis, the F statistic is typically used to assess adequate correla- Duncanville Fire Dept., Farmers Branch Fire Dept., Garland Fire
tion between T (time) and Z (distance) after accounting for X (im- Dept., Highland Park Dept. of Public Safety, Irving Fire Dept.,
portant confounders), with F greater than 10 indicating an adequate Lancaster Fire Dept., Mesquite Fire Dept., Plano Fire Dept., Uni-
instrument.39 In this study, we tested the appropriateness of distance versity Park Fire Dept.
as an instrument for all intervals in the primary sample and for total
EMS time in all subgroups. Only the subgroup of trauma patients University of Iowa Carver College of Medicine-Iowa Resusci-
treated in the United States fulfilled criteria for using distance as an tation Network, University of Iowa, Iowa City, IA: Richard
instrument (F test ⬎10), which restricted our use of instrumental Kerber, MD, Principal Investigator
variable analysis to this subgroup of patients. Core Investigators: Steve Hata, MD, Dianne Atkins, MD
Coordinators: Melanie Kenney, RN, MA, CPNP, Catherine
APPENDIX E2. ROC Epistry contributors. Rost, Alexander Drum, EMT-P, Michael Hartley, EMT-P
Alabama Resuscitation Center, University of Alabama at Bir- Participating EMS Agencies:
mingham, Birmingham, AL: Jeffrey D. Kerby, MD, PhD, Prin- Area Ambulance Service, Davenport Hospital Ambulance Corpo-
cipal Investigator ration, Covenant Health System - Covenant Ambulance, Cove-
Volume , .  : March  Annals of Emergency Medicine 246.e1

nant Health System - Mercy Oelwein, Covenant Health System - gela Marcantonio, Rina Marcantonio, CCHRA, Christine
Sartori, City of Dubuque Fire Dept., Dallas County Emergency Leclair, RN, Julie Cummins, RN
Medical Services, West Des Moines Emergency Medical Services, EMS Investigators/Collaborators: Matthew Stempien, MD, Jona-
Des Moines Fire Dept. EMS, Henry County Health Center than Dreyer, MD, Douglas Munkley, MD, Justin Maloney, MD,
Emergency Medical Services, Johnson County Ambulance, Paul Colella, MD, Andrew Affleck, MD, David Waldbillig,
Siouxland Paramedics, Inc., Waterloo Fire Rescue MD, Paul Bradford, MD, Martin Lees, MD, Vincent Arcieri,
MD, Ann Wilson, BSc, ACP, Kenneth Boyle, EMCA, RRT,
Milwaukee Resuscitation Research Center, Medical College of CMA, Lorraine Luinstra-Toohey, BScN, MHA, John Trickett,
Wisconsin, Milwaukee, WI: Tom P. Aufderheide, MD, Princi- BScN, Nicole Sykes, BScN, RN, Elaine Graham, ACP, Kieran
pal Investigator Ballah, EMCA, Cathy Hedges, A-EMCA, ACP, Paul Mathers,
Core Investigators: Ronald G. Pirrallo, MD, MHSA, Karen J. A-EMCA, Dug Andrusiek, MSc, Dan Bishop, ACP, Ron
Brasel, MD, MPH, Andrea L. Winthrop, MD, John P. Klein, Straight, ACP, Brian Twaites, ACP, Stuart Donn, PhD
PhD Participating EMS Agencies:
Coordinators: David J. Kitscha, BS, MS, Barbara J. Burja, BA, A.A. and M. Volunteer Ambulance Service, Burlington Fire and Res-
EMT, Chris von Briesen, BA, CCRC, Christopher W. Sparks, cue, Cambridge Fire Dept., Cornwall Fire and Rescue, Cornwall
EMT, Sara Kaebisch, BS SDG Emergency Medical Services, Essex-Windsor Emergency Med-
EMS Investigators/Collaborators: John Chianelli, MS, Rose- ical Services, Essex-Windsor Fire and Rescue, Frontenac Paramedic
marie Forster, MSOLQ, RHIA, EMT-P, Michael Milbrath, Service, Halton Emergency Medical Services, Harrow Ambulance
EMT-P, Lauryl Pukansky, BS, RHIA, Kenneth Sternig, MS- Service Ltd., Kawartha Lakes Emergency Medical Services, Kawartha
EHS, BSN, EMT-P, Eugene Chin, RN, EMT-P, Nancy Frieberg, Lakes Fire and Rescue, Kingston Fire and Rescue, Kitchener Fire
Dept., Lambton County Emergency Medical Services, Lasalle Fire
RN, EMT-P, Kim Krueger, RN, EMT-P, Del Szewczuga, RN,
Dept., London Fire Dept., Niagara Emergency Medical Services,
EMT-P Thomas Duerr, Rebecca Funk, BS, RHIA, EMT-B, Gail
Niagara Falls Fire and Rescue, Northumberland Emergency Medical
Jacobsen, BS, Janis Spitzer, Richard Demien, James Martins,
Service, Oakville Fire Dept., Ottawa Fire and Rescue, Ottawa Para-
John Cohn, Russell R. Spahn, MA, EMT-P, Mike Jankowski, BA,
medic Service, Peterborough Emergency Medical System, Peterbor-
EMT-P, Timothy James, William E. Wentlandt Jr., MBA, EFO,
ough Fire Dept., Prescott-Russell Emergency Medical Services, Sar-
David Berousek, Brian M. Satula, BA, NREMT, Jay B. Behling,
nia Fire Services, St. Catharine’s Fire and Rescue, Sudbury
BS, EMT-B, Dean K. Redman, BA, EFO, Steven Hook, BS,
Emergency Medical Services, Sudbury Fire and Rescue, SunParlour
CFOD, Andrew Neargarder, Jim Singer, RN
Emergency Services Inc., Superior North Emergency Medical Ser-
Hospital Investigators/Collaborators: Thomas Reminga, MD,
vices, Tecumseh Fire Dept., Thames Emergency Medical Services,
Dennis Shepherd, MD, Peter Holzhauer, MD, Jonathan Rubin,
Thunder Bay Fire and Rescue, Waterloo Fire and Rescue, Waterloo
MD, Craig Skold, MD, Orlando Alvarez, MD, Heidi Harkins, MD,
Regional Emergency Medical Services, Welland Fire and Rescue,
Edward Barthell, MD, William Haselow, MD, Albert Yee, MD,
Windsor Fire and Rescue, British Columbia Ambulance Service, Ab-
John Whitcomb, MD, Eduardo E. Castro, MD, Steven Motarjeme,
botsford Fire Dept., Aggassiz Valley Fire Dept., Burnaby Fire Dept.,
MD
Campbell River Fire Dept., Central Saanich Fire Dept., City of
Participating EMS Agencies: North Vancouver Fire Dept., Coquitlam Fire Dept., Delta Fire
Cudahy Fire Dept., Flight for Life, Franklin Fire Dept., Greendale Dept., Esquimalt Fire Dept., Kamloops Fire Dept., Kelowna Fire
Fire Dept., Greenfield Fire Dept., Hales Corners Fire Dept., Mil- Dept., Lake Country V Fire Dept., Langford Fire Dept., Langley
waukee County Airport Fire Dept., Milwaukee Fire Dept., North City Fire Dept., Langley Township Fire Dept., Maple Ridge Fire
Shore Fire Dept., Oak Creek Fire Dept., South Milwaukee Fire Dept., Mission Fire Dept., Nanaimo Fire Dept., New Westminster
Dept., St. Francis Fire Dept., Wauwatosa Fire Dept., West Allis Fire Fire Dept., North Vancouver District Fire Dept., Oak Bay Fire
Dept. Dept., Peachland Valley Fire Dept., Pitt Meadows Fire Dept., Port
Coquitlam Fire Rescue, Port Moody Fire Dept., Prince George Fire
Ottawa/OPALS/British Columbia RCC, Ottawa Health Re- Dept., Prince Rupert Fire Dept., Qualicum Beach Fire Dept., Rich-
search Institute, University of Ottawa, Ottawa, Ontario and mond Fire Dept., Saanich Fire Dept., Sooke V Fire Dept., Squamish
St. Paul’s Hospital, University of British Columbia, British Fire Dept., Surrey Fire Dept., Trail Fire Dept., Vancouver Fire
Columbia, Canada: Ian Stiell, MD, Principal Investigator Dept., Victoria Fire Dept., West Vancouver Fire Dept., Whistler Fire
Core Investigators: Jim Christenson, MD, Morad Hameed, Dept., White Rock Fire Dept.
MD, Jean Denis Yelle, MD, Martin Osmond, MD, Christian
Vaillancourt, MD, David Evans, MD, Riyad Abu-Laban, Pittsburgh Resuscitation Network, the University of Pitts-
MD burgh, Pittsburgh, PA: Clifton Callaway, MD, PhD, Principal
Coordinators: Cathy Clement, RN, Tammy Beaudoin, Investigator
CCHRA, Barb Boychuk, RN, Sarah Pennington, RN, Helen Core Investigators: Samuel Tisherman, MD, Jon Rittenberger,
Connolly, RN, Patrick Lefaivre, PCP, Jane Banek, CCHRA, An- MD, David Hostler, PhD
246.e2 Annals of Emergency Medicine Volume , .  : March 

Coordinators: Joseph Condle, Mitch Kampmeyer, Timothy Participating EMS Agencies:
Markham, Maureen Morgan Alpine Fire Protection District, American Medical Response, Ba-
EMS Investigators/Collaborators: Paul Sabol, Gina Sicchitano, rona Fire Dept., Bonita/Sunnyside Fire Protection, Borrego
Scott Sherry, Anthony Shrader, Greg Stull, Manuel Torres, MS, Springs Fire Protection District, Carlsbad Fire Dept., Chula Vista
William Groft, Robert McCaughan, Rodney Rohrer, John Cole, Fire Dept., Coronado Fire Dept., CSA-17 ALS Transporting
MD, David Fuchs, MD, Francis Guyette, MD, MS, William Agency, Deer Springs, Del Mar Fire Dept., East County Fire
Jenkins, MD, Ronald Roth, MD, Heather Walker, MD Protection District, El Cajon Fire Dept., Elfin Forest CSA 107,
Hospital Investigators/Collaborators: Alain Corcos, MD, Encinitas Fire Protection District, Escondido Fire Dept., Federal
Ankur Doshi, MD, Adrian Ong, MD, Andrew Peitzman, MD Fire Dept. San Diego, Imperial Beach Fire Dept., Julian-Cuy-
Participating EMS Agencies: amaca Fire Dept., La Mesa Fire Dept., Lakeside Fire Protection
Washington Ambulance and Chair, Pittsburgh Bureau of Emer- District, Lemon Grove Fire Dept., Mercy Air, Miramar Fire
gency Medical Services, Pittsburgh Bureau of Fire, Mutual Aid Dept., National City Fire Dept., North County Fire, Oceanside
Ambulance Service, STAT Medevac Fire Dept., Pala Fire Dept., Poway Fire Dept., Ramona Fire
Dept., Rancho Santa Fe Fire Protection District, San Diego Rural
Portland Resuscitation Outcomes Consortium, Oregon Fire Protection District, San Marcos Fire Dept., San Miguel Fire
Health and Science University, Portland, OR: Jerris R. Hedges, Protection District, Santee Fire Dept., Solana Beach Fire Dept.,
MD, MS, Principal Investigator Sycuan Fire Dept., Valley Center/Mercy Ambulance, Viejas Fire
Core Investigators: Craig D. Newgard, MD, MPH, Mohamud Dept., Vista Fire Dept.
R. Daya, MD, MS, Robert A. Lowe, MD, MPH
Coordinators: Denise Griffiths, BS, John Brett, EMT-P, Dana Seattle-King County Center for Resuscitation Research at the
Zive, MPH, Abdolaziz Yekrang, MPA, MA, Yoko Nakamura, University of Washington, University of Washington, Seattle,
MD, Brooke Frakes, BS, Aaron Monnig, EMT-P WA: Peter J. Kudenchuk, MD, Principal Investigator
EMS Investigators/Collaborators: Jonathan Jui, MD, MPH, Core Investigators: Tom D. Rea, MD, Eileen Bulger, MD,
Terri A. Schmidt, MD, MS, Ritu Sahni, MD, Craig R. Warden, Mickey S. Eisenberg, MD, Michael Copass, MD
MD, MPH, Marc D. Muhr, EMT-P2, John A. Stouffer, EMT-P, Coordinators: Michele Olsufka, RN, Sally Ragsdale, ARNP,
Kyle Gorman, MBA, EMT-P, Pontine Rosteck EMT-P, Karl Debi Solberg, RN, MN, Susan Damon, RN, Randi Phelps,
Koenig EMT-P, Jan Lee EMT-P, Roxy Barnes EMT-P, Heather Jeanne O’Brien, RN, MN
Tucker, EMT-P, Brad Allen, EMT-P, TJ Bishop, EMT-P, Adam EMS Investigators/Collaborators: Earl Sodeman, Marty
Glaser, EMT-P LaFave, James Boehl, Dave Jones, Gary Somers, Deborah Ayrs,
Hospital Investigators/Collaborators: Martin A. Schreiber, Adrian Whorton, Sam Warren, Jim Fogarty, Jonathan Larsen,
MD, Jim Anderson, MD, Ameen I. Ramzy, MD, K. Dean Mike Helbock
Gubler, DO, Lynn K. Wittwer, MD, Samantha Underwood, MS, Participating EMS Agencies:
Brooke Barone, BS, Denise Haun-Taylor, RN, Elizabeth Bryant, Bellevue Fire Dept., Redmond Fire Dept., Seattle Fire Dept.,
RN, Joanne Miller, ARNP Shoreline Fire Dept., King Co Medic 1, Vashon Island Medic
Participating EMS Agencies: One, Bothell Fire Dept., Burien Fire Dept., Kirkland Fire Dept.,
American Medical Response - Clackamas, Clark, and Multnomah Renton Fire Dept., Snoqualmie Fire Dept., Duvall Fire Dept.,
Counties, Camas Fire Dept., Clackamas County Fire District #1, Eastside Fire and Rescue, Enumclaw Fire Dept., Fall City Fire
Clark County Fire District #6, Lake Oswego Fire Dept., Life- Dept., Skyway Fire Dept., Kent Fire Dept., Maple Valley Fire and
Flight, MetroWest Ambulance, North Country Ambulance, Tu- Life Safety, Mercer Island Fire Dept., King County Fire District
alatin Valley Fire and Rescue, Vancouver Fire Department, Port- #44, North Highline Fire Dept., Northshore/Kenmore Fire
land Fire and Rescue, Portland International Airport Fire Dept., Port of Seattle Fire Dept., King County Fire District #47,
Department, Gresham Fire and Emergency Services King County Fire District #40, SeaTac Fire Dept., Skykomish
Fire Dept., Snoqualmie Pass, South King Co Medic 1, South
UCSD-San Diego Resuscitation Research Center, University King Fire and Rescue, Tukwila Fire Dept., Valley Regional Fire
of California at San Diego, San Diego, CA: Daniel Davis, MD, Authority, Vashon Island Fire and Rescue, Woodinville Fire
Principal Investigator Dept.
Core Investigators: David Hoyt, MD, Raul Coimbra, MD,
PhD, Gary Vilke, MD Toronto Regional Resuscitation Research Out of Hospital
Coordinators: Donna Kelly, RN, Lana McCallum-Brown, RN Network (Toronto Regional RESCUeNET), University of To-
EMS Investigators/Collaborators: Bruce Haynes, MD, Brad ronto, Toronto, Ontario, Canada: Arthur Slutsky, Principal In-
Schwartz, MD vestigator
Hospital Investigators/Collaborators: Michael Sise, MD, Core Investigators: Laurie Morrison, Paul Dorian
Frank Kennedy, MD, Fred Simon, MD, Gail Tominaga, MD, Coordinators: Craig Beers, Blair Bigham, Dina Braga, Grace
John Steele, MD Burgess, Bruce Cameron, Suzanne Chung, Pete De Maio, Steve
Volume , .  : March  Annals of Emergency Medicine 246.e3

Driscoll, Lynne Fell, Jamie Frank, Mark McLennan, Lesley Ann OrngeTransport Medicine, Oro Medonte Fire and Emergency
Molyneaux, Welson Ryan, Angela Schotsman, Jacob Simonini, Services, Oshawa Fire Services, Pickering Fire Services, The Ra-
Lynda Turcotte, Flo Veel, Amy Wassenaar, Cathy Zahn mara Township Fire and Rescue Service, Peel Regional Paramedic
EMS Investigators/Collaborators: Dana Bradshaw, Rob Bur- Services, Toronto EMS, Toronto Fire Services, Township of Essa
gess, Bruce Cameron, Sandra Chad, Sheldon Cheskes, Allan Fire Dept., Township of Georgian Bay Fire Dept., Township of
Craig, Steve Dewar, Tim Dodd, Rob Duquette, Marty Epp, Mi- Scugog Fire Dept., Township of Uxbridge Fire Dept., Wasaga
chael Feldman, Verena Jones, Russell MacDonald, Larry Beach Fire Dept., Whitby Fire and Emergency Services, Durham
MacKay, Steve McNenley, Judy Moore, Philip Moran, Michael Regional Basehospital, Sunnybrook Osler Center for Prehospital
Murray, Michael Nemeth, Russ Olnyk, Tyrone Perreira, Richard Care, Hamilton Health Sciences Paramedic Base Hospital Pro-
Renaud, Karen Roche, Jennifer Shield, Doug Silver, Jacob gram, Simcoe Muskoka Basehospital
Stevens, Rick Verbeek, Tim Waite, Ken Webb, Michelle Wels-
ford Steering Committee Chair, Myron Weisfeldt, MD, Johns Hopkins
Hospital Investigators/Collaborators: Rosemarie Farrell, Jamie
University School of Medicine, Baltimore, MD, Co-Chair-Cardiac,
Hutchison
Joseph P. Ornato, MD, Virginia Commonwealth University Health
Participating EMS Agencies:
System, Richmond, VA, Co-Chair-Trauma, David B. Hoyt, MD,
Ajax Fire and Emergency Services, Barrie Fire and Emergency
University of California at San Diego, San Diego, CA, replacing Col.
Service, Beausoleil First Nation Emergency Medical Services,
Bradford West Gwillimbury Fire and Emergency Services, John B. Holcomb, MD, Commander, U.S. Army ISR
Brampton Fire and Emergency Services, Brock Township Fire National Heart, Lung, and Blood Institute, Bethesda, MD:
Dept., Caledon Fire and Emergency Services, City of Hamilton Tracey Hoke, MD, George Sopko, MD, MPH, David Lathrop,
Emergency Services – EMS, City of Hamilton Emergency Ser- PhD, Alice Mascette, MD, Patrice Desvigne Nickens, MD
vices – Fire, City of Orillia Fire Dept., Clarington Emergency and Clinical Trial Center, University of Washington, Seattle, WA:
Fire Services, County of Simcoe Paramedic Services, Durham Al Hallstrom, PhD, Graham Nichol, MD, MPH, Scott Emerson,
Regional Emergency Medical Services, Innisfil Fire and Rescue MD, PhD, Judy Powell, BSN, Gena Sears, BSN, Berit Bardarson,
Service, Mississauga Fire and Emergency Services, Mnjikaning RN, Lois Van Ottingham, BSN, Anna Leonen, MS, Robert B.
Fire Rescue Service, Muskoka Ambulance Service, Muskoka Am- Ledingham, MS, Chris Finley, Richard Moore, BS, Ben Bergsten-
bulance Communication Center, New Tecumseth Fire Dept., Buret
246.e4 Annals of Emergency Medicine Volume , .  : March 

Emergency Medical Services Intervals and Survival in Trauma: Assessment of The "Golden Hour" in A North American Prospective Cohort

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EMERGENCY MEDICAL SERVICES/ORIGINAL RESEARCH

Emergency Medical Services Intervals and Survival in Trauma:

Provide feedback on this article at the journal’s Web site, www.annemergmed.com.

Volume , .  : March  Annals of Emergency Medicine 235

response interval. Meeting such expectations requires

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Figure 1. Flow diagram of patients included in the primary analysis.

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When the sample was expanded to include injured adults

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Volume , .  : March  Annals of Emergency Medicine 245

American Board of Emergency Medicine

Hospice and Palliative Medicine

Undersea and Hyperbaric Medicine

AMERICAN BOARD OF EMERGENCY MEDICINE

246 Annals of Emergency Medicine Volume , .  : March 

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