Overview

The impact of time intervals on outcomes in the prehospital setting has been exhaustingly debated.
There has been a tonne of research on the subject, but there are a lot of problems that researchers
tend to run into repeatedly. The biggest one seems to be correlation vs causation. A patient trapped
in a crushed vehicle after a highway collision is going to have a longer scene time and higher
probability of a bad outcome than a patient who fell down 5 stairs, but we can all recognize that the
clumsy guy didn’t have a better outcome because we got him off the floor and off scene faster – he
had a better outcome because he wasn’t crushed by his dashboard at 180kph+.

A big part of the research that has been done is retrospective – analyzing data that wasn’t gathered
for this purpose and wasn’t a part of controlled trials. As a result, there are a lot of uncontrolled
variables. For example, most EMS crews are not documenting how many minutes the extrication
took, or how long they treated on scene after extricating but before transporting. Very little is
standardized.

There may be an urban service that can have 8 ambulances and a professional fire department on
scene of an MVC and they’re 10 minutes from a trauma center, while the other service has one
ambulance, five volunteer firefighters, and they’re 40min from a rural hospital. The data from a state-
wide database may not differentiate these variables, or the researchers may not account for response
and transport times. Scene times are not the whole picture.

For the sake of brevity, let’s just say that this topic has a huge number of important variables that are
difficult to account for. They do their best though, and there is some good data out there.

Research

The majority of the studies I was able to review came to very similar conclusions, both from their own
data as well as the literature they reviewed themselves. What is clear is that in a modern EMS system,
asking whether scene times are associated with worse outcomes in trauma is a severe
oversimplification.

Here’s the big picture: increased prehospital times do not appear to worsen outcomes in
undifferentiated or blunt trauma patients, but they do matter in patients who are hemodynamically
unstable, have penetrating trauma, flail chest, or TBI. These are truly time-sensitive injuries.

A few of the papers I looked at stood out. A systematic review (Harmsen, et al., 2015) found that
while penetrating trauma and TBI patients have better outcomes with shorter times, all other
(“undifferentiated“) types of patients seem to do better with longer on-scene times, stating that this
is “presumably related to the comprehensive care that is delivered prehospitally, implying that for
the future, the emphasis should not be on getting a patient to the hospital as fast as possible but
making sure the patients receive proper prehospital care first” (Harmsen, et al., 2015, p. 14).

McCoy et al. (2013) reviewed a database of 19,167 patients and found that, of all the variables they
accounted for, the only one that worsened mortality was penetrating trauma with a transport time
>20mins.

One particularly interesting (and large) study by Brown et al. (2016) analyzed the data from 164,471
trauma patients in Pennsylvania, looking at the relationship between prehospital time intervals and
in-hospital mortality. The initial general result was that increased scene time was associated with a
21% increase in mortality, but when they played with the numbers they found that many of the
prolonged scene times were due to extrication or intubation. When they adjusted for this, they found
that the increased scene times did not correlate with an increase in mortality. Extrication and
intubation were associated with worse outcomes, but this is an understandable correlation (worse
injuries). They found that longer scene times did not increase mortality in patients not requiring
extrication or intubation.

Several of the studies I reviewed found that intubation of severely head injured patients is worth
taking the time for in the prehospital environment, as it improves outcomes.

Relevance

The relevance of this topic to EMS is obvious. The question of whether trauma scene times influences
patient outcomes is potentially practice-changing, or even system-changing. For example, my own
managers have told me that our system is programmed to flag PCRs that indicate >10min on-scene
time for a trauma. Where did this number come from? Is it arbitrary? In fact, some research has
suggested that prolonged on-scene times for certain types of trauma calls is beneficial for patients,
because we are providing them with the medical care they need. “For undifferentiated trauma
patients, focus should be on the type of care delivered prehospital and not on rapid transport.”
(Harmsen, et al., 2015, abstract).

EMS professionals in a modern system should instead be able to make educated decisions about
whether a patient will likely benefit from prehospital interventions, or requires rapid transport to a
definitive care center. Broadly applying the “scoop-and-run” approach to all trauma patients may
benefit some of them, but it may be detrimental to others. As research on this topic continues we will
be better able to make these distinctions.

References:

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Brown, J. B., Rosengart, M. R., Forsythe, R. M., Reynolds, B. R., Gestring, M. L., Hallinan, W. M., ... &
Sperry, J. L. (2016). Not all prehospital time is equal: Influence of scene time on mortality. The journal
of trauma and acute care surgery, 81(1), 93.

Dinh, M. M., Bein, K., Roncal, S., Byrne, C. M., Petchell, J., & Brennan, J. (2013). Redefining the golden
hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient
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Feero, S., Hedges, J. R., Simmons, E., & Irwin, L. (1995). Does out-of-hospital EMS time affect trauma
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Gonzalez, R. P., Cummings, G. R., Phelan, H. A., Mulekar, M. S., & Rodning, C. B. (2009). Does
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Harmsen, A. M. K., Giannakopoulos, G. F., Moerbeek, P. R., Jansma, E. P., Bonjer, H. J., & Bloemers, F.
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